2025 Prior Authorization Grids

Medical

• Medical Prior Authorization Grid | Effective 01/23/2025
  Applies to: Banner Medicare Advantage Dual HMO D-SNP, Banner Medicare Advantage Prime HMO
• Medical Prior Authorization Grid | Effective 01/23/2025
  Applies to: B – UFC/ACC, B – UFC/ALTCS

Pharmacy

Applies to: B – UFC/ACC, B – UFC/ALTCS

• Pharmacy Prior Authorization Grid | Effective 11/01/2024 - 5/31/2025
  
• Pharmacy Prior Authorization Grid | Effective 06/01/2025 - 08/04/2025
• Pharmacy Prior Authorization Grid | Effective 08/05/2025 

Behavioral Health

Applies to: B – UFC/ACC, B – UFC/ALTCS

• Behavioral Health Prior Authorization Grid | Effective 03/01/2025

ALTCS Services

Applies to: B – UFC/ALTCS

• ALTCS Services Prior Authorization Grid | Effective 01/01/2025 

Medical Medication Step Therapy Guide

Applies to: B – UFC/ACC, B – UFC/ALTCS

• Medical Medication Step Therapy Guide | Effective 11/01/2024-5/31/2025
• Medical Medication Step Therapy Guide | Effective 06/01/2025 - 07/31/2025
• Medical Medication Step Therapy Guide | Effective 08/01/2025