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)
- CalViva Health – Fresno, Kings and Madera counties (PDF)
- Centene Corporation Employee Medical Benefits Plan (PDF)
- Commercial and Medicare – California (PDF)
- CommunityCare HMO
- CommunityCare HMO Participating Physician Groups
- Direct Network HMO, Point of Service (POS) Tier 1 and Medicare Advantage HMO
- EPO (including PureCare)
- Point of Service Tiers 2 and 3 (Elect, Select and Open Access)
- PPO, Out-of-State PPO, and Flex Net product
- Medi-Cal Fee-for-Service (Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, and Tulare counties) (PDF)
- Medi-Cal Los Angeles County Department of Human Services (LA-DHS) Participating Physician Groups (PDF)
Prior Authorization Request Form
- Commercial Group plans HMO, POS, PPO, EPO, Flex Net, Medicare Advantage Group plans, Cal MediConnect (PDF)
- Commercial Individual plans – Outpatient (PDF)
- Commercial Individual plans – Inpatient (PDF)
- Medicare Advantage Individual plans – Outpatient (PDF)
- Medicare Advantage Individual plans – Inpatient (PDF)
- MediCal (PDF)
- CalViva (PDF)