Top payers by prior authorization policies25

• UnitedHealthcare2,378 prior auth policiesUpdated 2026-08-01Prior authorization requirements for Virginia Cardinal Care LTSSEff. 2026-05-01Lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Virginia Long-Term Support Services (LTSS) providers for inpatient and outpatient services.All UnitedHealthcare policy updates
• Cigna2,037 prior auth policiesUpdated 2026-09-01Drugs Requiring Medical Necessity Review (product-specific prior authorization list)Eff. 2026-06-15Defines medical necessity review requirements and preferred product step requirements for various drugs under Cigna-administered health benefit plans; affects providers submitting prior authorization requests and Cigna medical directors making coverage determinations.All Cigna policy updates
• Colorado Rocky Mountain Health Plans1,796 prior auth policiesUpdated 2026-09-01Medical Records Documentation Used for Reviews — Documentation requirements for prior authorization and utilization reviewEff. 2026-07-01Lists the types of medical record documentation that may be requested and used during coverage and utilization reviews across many clinical service categories; intended for providers submitting prior authorization or review requests to the payer.All Colorado Rocky Mountain Health Plans policy updates
• Neighborhood Health Plan Of Rhode Island1,221 prior auth policiesUpdated 2026-06-01Non-Emergent Ambulance Transportation Prior Authorization RequirementEff. 2026-01-01Requires prior authorization for certain non-emergent air and ground ambulance services for members enrolled in Neighborhood INTEGRITY for Duals (HMO D-SNP) and Dual CONNECT (HMO D-SNP). Affects providers submitting claims for these members.All Neighborhood Health Plan Of Rhode Island policy updates
• Centene1,006 prior auth policiesUpdated 2026-06-01Prior Authorization (PA) requirements for CalViva Health Medi‑Cal FFSEff. 2026-01-01Lists services, procedures, equipment, timelines, submission instructions, and prior authorization requirements that govern PA for CalViva Health Medi‑Cal fee‑for‑service members in Fresno, Kings, and Madera counties; affects providers submitting PA requests for those members.All Centene policy updates
• Mhn856 prior auth policiesUpdated 2026-04-01Prior Authorization Requirements — CalViva Health Medi‑Cal FFSEff. 2026-04-01Governs prior authorization (PA) requirements, submission rules, timelines, and which services require PA for CalViva Health Medi‑Cal fee‑for‑service members in Fresno, Kings, and Madera counties.All Mhn policy updates
• AvMed636 prior auth policiesUpdated 2026-07-01Medical Prior Authorization Requirements / Medical Procedures GuidelinesEff. 2025-12-19Governs AvMed's prior authorization requirements, delegates, and processes for medical procedures and services for all AvMed members and product lines; affects providers (in-network and out-of-network), delegated vendors, and members in North Carolina and nationally where specified.All AvMed policy updates
• Mass General Brigham Health Plan609 prior auth policiesUpdated 2026-08-01Medical Specialty Medications — MassHealth Prior Authorization Code ListEff. 2026-05-01This document lists medical specialty medications and associated billing codes and attributes for MassHealth prior authorization effective 05/01/2026; it governs prior authorization handling for these specialty drugs under the Mass General Brigham Health Plan for the MassHealth program.All Mass General Brigham Health Plan policy updates
• Blue Cross Blue Shield - Nebraska480 prior auth policiesUpdated 2026-07-01Total Knee and Hip Replacement — Preauthorization Requirement for Specified Member GroupsEff. 2013-10-01Policy governing preauthorization and coverage requirements for total knee and total hip replacement for specified BCBSNE member groups (EHA, MUD, BCBSNE employees/dependents, and Individual ACA). Applies to those identified product prefixes and the providers submitting claims for those members.All Blue Cross Blue Shield - Nebraska policy updates
• Blue Cross Blue Shield - Massachusetts454 prior auth policiesUpdated 2026-08-01Medical Benefit Prior Authorization Medication ListEff. 2026-05-01Lists medications that require prior authorization when provided under the member's medical benefit in certain outpatient settings and identifies member types to which the requirement applies.All Blue Cross Blue Shield - Massachusetts policy updates
• Anthem433 prior auth policiesUpdated 2026-06-01Georgia Local Precertification/Prior Authorization ListEff. 2026-04-01Lists services and CPT codes that require precertification/prior authorization for local fully‑insured Anthem Blue Cross and Blue Shield members in Georgia and certain ASO members; excludes BlueCard, Medicare Advantage, Medicaid, Medicare Supplement, and FEP members.All Anthem policy updates
• Health Net424 prior auth policiesUpdated 2026-05-01Prior Authorization Requirements — CalViva Health Medi‑Cal FFS (Fresno, Kings, Madera)Lists services, procedures, equipment and outpatient pharmaceuticals subject to prior authorization for CalViva Health Medi‑Cal FFS members in Fresno, Kings and Madera counties and explains submission and timeline rules for providers.All Health Net policy updates
• Blue Cross Blue Shield - Iowa393 prior auth policiesUpdated 2026-08-28Federal Employee Program (FEP) Medical Prior Authorization Drug ListEff. 2026-04-09All Blue Cross Blue Shield - Iowa policy updates
• Viva Health333 prior auth policiesUpdated 2026-07-01Bevacizumab (and listed biosimilars) — Intravenous oncology coverage and prior authorization criteriaEff. 2008-10-17Clinical coverage and prior authorization criteria for bevacizumab and listed biosimilars for oncology indications for Viva Health members; defines authorization length, dosing unit limits, and indication-specific clinical criteria.All Viva Health policy updates
• Ambetter Georgia306 prior auth policiesUpdated 2026-03-01Berotralstat (Orladeyo) and assorted pharmacy prior authorization updatesEff. 2026-02-01Covers prior authorization, coding, and coverage-related updates for multiple pharmacy policies with a primary heading of Berotralstat (Orladeyo); affects Ambetter Georgia providers requesting pharmacy-covered medications listed in the document.All Ambetter Georgia policy updates
• Eocco267 prior auth policiesUpdated 2026-07-09Krystexxa (pegloticase) (Intravenous) — Prior Authorization and Coverage CriteriaEff. 2026-07-01Defines prior authorization, dosing limits, approval and renewal criteria, billing codes, and covered diagnoses for use of Krystexxa (pegloticase) for chronic gout in adults.All Eocco policy updates
• Careoregon252 prior auth policiesUpdated 2026-08-01Pharmacy & Specialty Drugs — Coverage Criteria (Abilify Mycite and listed specialty drug prior authorization criteria)Eff. 2026-07-26This policy lists prior authorization criteria and coverage requirements for Abilify Mycite (Maintenance and Starter Kits) and multiple specialty pharmacy products; it specifies required documentation, prerequisite therapy, prescriber restrictions, initial and renewal coverage durations, and exclusions for CareOregon members.All Careoregon policy updates
• Fidelis Care251 prior auth policiesUpdated 2026-06-01Oncology Services - Medicare | Oncology medication prior authorization and billing list (Wellcare by Fidelis Care)Eff. 2026-06-01Defines Evolent review/prior authorization requirements and lists HCPCS/HCPCS-like and pharmacy codes for oncology medications and supportive agents for Wellcare by Fidelis Care Medicare members; includes out-of-scope items and preferred biosimilar agents. Applies to dispensing at pharmacy or administration in physician office, outpatient hospital, or ambulatory settings.All Fidelis Care policy updates
• Meridian230 prior auth policiesUpdated 2026-08-01Axitinib (Inlyta) — Coverage and Prior AuthorizationEff. 2024-12-01Defines medical necessity criteria, prior authorization requirements, and approval durations for axitinib (Inlyta) for Medicaid members, including FDA-approved and selected off-label indications and continuation criteria.All Meridian policy updates
• Blue Cross Blue Shield - Rhode Island220 prior auth policiesUpdated 2026-10-01Medical-benefit prior authorization for specified drugs (MDR Drug Listing)Eff. 2020-07-01Notifies Medicare Advantage members and providers that, effective July 1, 2020, an expanded list of drugs administered under the medical benefit will require prior authorization handled by Prime Therapeutics for BCBSRI members; applies to office and hospital outpatient administrations.All Blue Cross Blue Shield - Rhode Island policy updates
• Medical Mutual - Ohio206 prior auth policiesUpdated 2026-06-03CPT/HCPCS Prior Authorization Code List — Commercial & Medicare AdvantageEff. 2026-05-01Lists CPT/HCPCS codes, prior authorization requirements, submission processes, and vendor-managed delegations for Commercial and Medicare Advantage plans administered by Medical Mutual - Ohio.All Medical Mutual - Ohio policy updates
• Mississippi Division Of Medicaid203 prior auth policiesUpdated 2026-08-01Prior authorization requirement for outpatient hospital mental health servicesEff. 2022-05-01This notice adopts an administrative rule requiring prior authorization for all outpatient hospital mental health services under Mississippi Medicaid; it affects providers delivering outpatient hospital mental health services to Mississippi Medicaid beneficiaries.All Mississippi Division Of Medicaid policy updates
• CareSource183 prior auth policiesUpdated 2026-07-011915(c) HCBS fee schedule, prior authorization and invoice requirements — ArkansasEff. 2026-01-01Defines covered HCBS service codes, modifiers, units, fee schedules, prior authorization and invoice requirements for CareSource members in Arkansas under the 1915(c) program effective January 1, 2026.All CareSource policy updates
• Aetna181 prior auth policiesUpdated 2025-07-01Cinryze (C1 esterase inhibitor, human) Medication Precertification Request Form and RequirementsAetna precertification form and requirements for requesting initial or continuation authorization for Cinryze infusion therapy, intended for providers and facilities submitting precertification for members in North Carolina.All Aetna policy updates
• Premera Bluecross179 prior auth policiesUpdated 2026-09-01Genetic testing prior authorization and code listEff. 2024-01-01This document lists services requiring prior authorization for Federal Employees Health Benefits (FEHB) members and includes an extensive list of genetic testing CPT/HCPCS/PLA codes; it applies to providers serving FEHB (FEP) members. It identifies penalties for failure to obtain required precertification/prior approval for certain programs.All Premera Bluecross policy updates