Centene Prior Authorization Lookup
Latest Centene prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Home VentilatorsMedical necessity criteria for initial and continued use of noninvasive and invasive home ventilators for non‑Medicare Centene-affiliated plans; who qualifies and documentation/prior authorization expectations.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Applied Behavioral Analysis (ABA) Documentation RequirementsDefines required clinical documentation elements and recordkeeping standards for ABA services when covered by Centene-affiliated health plans; applies to providers delivering ABA (technicians, supervisors/Qualified Healthcare Providers) and affects prior authorization, billing, and payment.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Ambetter Formulary (Prescription Drug List) - January 2026This document is the Ambetter prescription drug formulary (Prescription Drug List) effective January 1, 2026; it describes covered drugs, tiering, formulary keys/abbreviations, prior authorization process for non-formulary drugs, quantity/age/step-therapy limits and specialty/split-fill handling. Part 1 contains general formulary policies, drug list key definitions, opioid fill limits, and many sample drug entries with tiers and limits (partial list).All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Ambetter Formulary (Prescription Drug List) — Coverage CriteriaDefines the Ambetter prescription drug formulary, tiers, coverage guidance, prior authorization and limits for covered drugs under the Centene/Ambetter benefit; affects providers prescribing and dispensing prescription and specialty drugs to Ambetter members.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Ambetter Formulary (Prescription Drug List) — Coverage CriteriaDefines the Ambetter prescription drug formulary, tiering, prior authorization, quantity limits, step therapy, specialty pharmacy requirements, and opioid prescribing limits for members covered under the plan.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Ambetter Formulary (Prescription Drug List) — Coverage CriteriaThis document governs the Ambetter prescription drug formulary (January 1, 2026) including coverage tiers, prior authorization, step therapy, quantity and age limits, specialty drug routing, and limits for opioid prescriptions; it affects providers and members served under the Ambetter/Centene prescription drug benefit.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Ambetter Formulary (Prescription Drug List) — Coverage CriteriaThis document governs the Ambetter prescription drug formulary (2026) describing covered drugs, tiering, utilization management (prior authorization, step therapy, quantity limits), specialty drug handling, and opioid limits for members and providers under Centene's Ambetter plans.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Ambetter Health Formulary (Prescription Drug List) — Coverage CriteriaDefines the Ambetter Health prescription drug formulary, tiering, coverage designations (PA, ST, QL, NF, SP) and prior authorization/coverage processes for Ambetter prescription drug benefits.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Ambetter Prescription Drug Formulary — Coverage CriteriaDefines the Ambetter prescription drug formulary tiers, coverage notes (prior authorization, step therapy, quantity and age limits), specialty pharmacy handling, and opioid fill limits for members under this plan.All Centene updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Inpatient California Medi‑Cal Prior AuthorizationGoverns prior authorization requests for inpatient services for California Medi‑Cal enrollees handled by Centene/Health Net. Applies to requesting and servicing providers submitting inpatient authorization requests and specifies required fields, timelines, and documentation expectations.All Centene updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Medicare Inpatient Authorization — Health Net CaliforniaThis document governs prior authorization request completion and submission for Medicare inpatient admissions for Health Net California (Centene) members; it affects requesting and servicing providers and facilities submitting standard or expedited authorization requests.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Outpatient Authorization Form for California Health Net Medi‑Cal (Transplant-related services)This document is an outpatient prior authorization request form used by providers to request authorization for outpatient services (including transplant evaluation and transplant surgery) for Health Net of California Medi‑Cal members. It governs what information must be submitted to obtain prior authorization and informs timing expectations for standard and urgent requests.All Centene updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Outpatient California Health Net Medi-Cal Authorization FormForm and instructions governing prior authorization requests for outpatient services for Health Net Medi-Cal members in California; used by requesting and servicing providers to submit authorization requests, supplemental procedure codes, and supporting clinical information.All Centene updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Prior Authorization (PA) requirements for CalViva Health Medi‑Cal FFSLists 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 updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Prior Authorization Requirements for CHPIV Medi‑Cal FFS MembersDefines prior authorization (PA) requirements, submission processes, timelines, and services subject to PA for Community Health Plan of Imperial Valley (CHPIV) Medi‑Cal fee‑for‑service members; affects providers serving CHPIV Medi‑Cal enrollees in Imperial County.All Centene updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-12-31Ambetter Health CMS Final Rule 0057-F Prior Authorization RequirementsPublishes Ambetter Health prior authorization (PA) requirements and related operational guidance effective 12/31/2025; applies to providers and services delivered to Ambetter Health members across the plan's products.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-01Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and B-ThalassemiaMedical necessity criteria and coverage stance for allogeneic hematopoietic cell transplantation (HCT) to treat sickle cell anemia and homozygous B-thalassemia for Centene-affiliated health plans; intended for clinicians and prior authorization staff.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-25Duobrii (halobetasol propionate / tazarotene) topical lotion — coverage criteriaClinical policy governing medical necessity and prior authorization requirements for Duobrii (halobetasol propionate 0.01%/tazarotene 0.045%) topical lotion for treatment of plaque psoriasis in adults across Centene lines of business.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Applied Behavior Analysis (ABA) for Autism Spectrum DisorderDefines medical necessity, clinical requirements, settings, and documentation standards for coverage of Applied Behavior Analysis (ABA) services for members with Autism Spectrum Disorder (ASD) under Centene plans. Affects providers delivering ABA and BCBA supervisors, and payers managing prior authorization and continuing care.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-03-01Eculizumab (Soliris) and biosimilars coverageDefines medical necessity, prior authorization, and dosing criteria for Soliris and its biosimilars (eculizumab-aeeb, eculizumab-aagh) across indications including PNH, aHUS, gMG, and NMOSD for Centene lines of business.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Ambetter Health 2025 Formulary (prescription drug list)Defines Ambetter Health's 2025 prescription drug formulary: tiers, coverage principles, prior authorization and limits (quantity limits, age limits, step therapy, specialty fill rules) and selected drug-specific tier/limit/PA entries included in this part of the formulary.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Ambetter Health Formulary (Prescription Drug List) - Coverage CriteriaThis document describes the Ambetter Health Formulary (prescription drug list), coverage tiers, formulary keys (PA, QL, AL, ST, NF, SP, SF), prior authorization processes, opioid new-start limits, and pharmacy-related fill requirements for members covered by Ambetter plans.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Ambetter Health Formulary (Prescription Drug List) — Coverage CriteriaDefines the Ambetter Health prescription drug formulary, tier structure, and coverage controls (prior authorization, step therapy, quantity/age limits) that govern pharmacy benefits for members covered by this plan.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Ambetter Health Formulary (Prescription Drug List) — Coverage CriteriaThis document governs the Ambetter Health prescription drug formulary (covered brand and generic drugs), formulary tiers, prior authorization and quantity/age limits, and specialty drug handling for Ambetter members. It affects providers prescribing medications and pharmacies dispensing under Ambetter plans.All Centene updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Ambetter Health Formulary — Prescription Drug Coverage Criteria (Pharmacy & Specialty Drugs)Governance of covered prescription drugs, tiers, and utilization management (prior authorization, step therapy, quantity limits, specialty rules) for members under the Ambetter formulary. Affects prescribers, pharmacies, and Ambetter members.All Centene updates
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Tool Description
Search Centeneprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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