Prior Authorizations
Services Requiring Prior Authorization – California
Please confirm the member's plan and group before choosing from the list below.
Providers should refer to the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI) to determine exclusions, limitations and benefit maximums that may apply to a particular procedure, medication, service, or supply.
Refer to the Pharmacy section of the website for information regarding prescription authorization requirements.
Prior Authorization Lists
- Medi-Cal Fee-for-Service Health Net, CalViva Health and Community Health Plan of Imperial Valley (CHPIV)
- Amador, Calaveras, Inyo, Los Angeles (including Molina providers), Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties
- Fresno, Kings and Madera counties – CalViva Health (PDF)
- Imperial County – Community Health Plan of Imperial Valley (CHPIV) (PDF)
- Medi-Cal Los Angeles County Department of Human Services (LA-DHS) Participating Physician Groups
- Commercial – California
- Direct Network HMO (including Ambetter HMO) and Point of Service (POS) Tier 1
- POS Tiers 2 and 3 (Elect, Select and Open Access)
- Ambetter HMO participating physician groups (PPGs)
- PPO (including Ambetter), out-of-state PPO
- Medicare – California
- Wellcare By Health Net Medicare Advantage (MA) PPO and HMO Direct Network
Prior Authorization Request Form
Inpatient forms
- Commercial plans – Inpatient (PDF)
- Medicare Advantage plans – Inpatient (PDF)
- Medi-Cal – Prior Authorization Request Form – Inpatient (PDF)
- CalViva Health – Prior Authorization Request Form – Inpatient (PDF)
- Community Health Plan of Imperial Valley – Prior Authorization Request Form – Inpatient (PDF)
Outpatient forms
- Commercial plans – Outpatient (PDF)
- Medicare Advantage plans – Outpatient (PDF)
- Medi-Cal – Prior Authorization Request Form – Outpatient (PDF)
- CalViva Health – Prior Authorization Request Form – Outpatient (PDF)
- Community Health Plan of Imperial Valley – Prior Authorization Request Form – Outpatient (PDF)
Intermediate Care Facility (ICF) forms
- Health Net – Prior Authorization Request Form – ICF (PDF)
- CalViva Health – Prior Authorization Request Form – ICF (PDF)
- Community Health Plan of Imperial Valley – Prior Authorization Request Form – ICF (PDF)