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
- Cal MediConnect (PDF)
- Medi-Cal Fee-for-Service Health Net and CalViva Health
- Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, and Tulare counties
- Fresno, Kings and Madera counties – CalViva Health (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
- Health Care Service Plan (HSP)
- POS Tiers 2 and 3 (Elect, Select and Open Access)
- Ambetter HMO participating physician groups (PPGs)
- EPO, PPO, out-of-state PPO and Flex Net
- Medicare – California
- Wellcare By Health Net Medicare Advantage (MA) PPO and HMO Direct Network
Prior Authorization Request Form
- Commercial plans – Outpatient (PDF)
- Commercial plans – Inpatient (PDF)
- Medicare Advantage plans – Outpatient (PDF)
- Medicare Advantage plans – Inpatient (PDF)
- Medi-Cal – Prior Authorization Request Form – Outpatient (PDF)
- Medi-Cal – Prior Authorization Request Form – Inpatient (PDF)
- CalViva Health – Prior Authorization Request Form – Outpatient (PDF)
- CalViva Health – Prior Authorization Request Form – Inpatient (PDF)