The documents below list services and medications that require prior authorization for patients with Medicaid, Medicare Advantage and dual Medicare-Medicaid coverage.

Prior authorization search tool

Search by CPT code, procedure or drug name to see if prior authorization is required. 

Medicare

Medicare Part B Step Therapy Preferred Drug List change notifications 

  • Medicare prior authorization list summary of changes

Current prior authorization and notification lists

  • July 1, 2025, Humana Gold Plus® Integrated Illinois Dual Medicare-Medicaid Plan Prior Authorization and Notification List
  • July 1, 2025, Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
  • July 1, 2025, Humana Dual Fully Integrated Virginia Prior Authorization and Notification List
  • January 1, 2025, Part B Step Preferred Drug List
  • January 1, 2025, Humana Gold Plus® Integrated Medicare-Medicaid Illinois Long-Term Services and Supports (LTSS) Plan Prior Authorization and Notification List (PAL)
  • Effective July 1, 2025, Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Prior Authorization and Notification List

Future prior authorization and notification lists

  • October 1, 2025, Humana Gold Plus Integrated Illinois Dual Medicare-Medicaid Plan Prior Authorization and Notification List
  • October 1, 2025,  Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List

Previous prior authorization and notification lists

  • January 1, 2025, Humana Gold Plus Integrated Illinois Dual Medicare-Medicaid Plan Prior Authorization and Notification List
  • January 1, 2025, Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
  • January 1, 2025, Puerto Rico Medicare and Dual Medicare-Medicaid Prior Authorization and Notification List
  • July 1 2024, Part B Step Preferred Drug List
  • July 1 2024, Humana Gold Plus Integrated Illinois Dual Medicare-Medicaid Plan Prior Authorization and Notification List
  • July 1 2024, Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
  • January 1, 2024, Puerto Rico Medicare and Dual Medicare-Medicaid Prior Authorization and Notification List
MedicaidState-specific prior authorization statisticsCommercial

How to submit requests

Save time by reviewing what to include in your prior authorization.

What to include in a prior authorization

Basic information

  • Physician and facility information, including Tax Identification Number and National Provider Identifier (NPI) of requesting provider and servicing provider
  • Patient name, date of birth and member ID
  • Date of service
  • Contact information for person who can provide clinicals and answer questions

Letter of medical necessity

  • Summary statement of medical need and reason for request

Summary of patient’s diagnosis

  • Date of diagnosis, diagnostic and imaging results
  • Current severity of patient’s conditions
  • Any previously attempted treatments or patient intolerance to these treatments

Summary of patient’s history

  • Previously administered treatments, procedures and dates
  • Response to these treatments
  • Recent symptoms and conditions
  • Physician opinion of patient prognosis and disease progression

Medical

Determine coverage and start the prior authorization process in Availity. Or view fax forms

Pharmacy

Submit and track prior authorizations with CoverMyMeds. Or view fax forms .

Prior authorization resources

Use the links below to submit the prior authorization form, find other forms or learn more about the process.

Coverage criteria

Search coverage, medical and pharmacy criteria.

Medical and pharmacy coverage criteria

Fax forms

Download a form to submit your prior authorization by fax.

Standard form

Texas form

New Mexico form

Indiana form

Arizona form

State exemptions

For more information, please see the FAQs below for specific state exemptions.

Texas exemptions

Texas House Bill 3459 – Prior Authorization Exemptions

Louisiana exemptions

Louisiana Senate Bill 112 – Prior Authorization Exemptions

Explore featured resources