Prior Authorizations

2024 Prior Authorization Guide - Effective 1/1/2024
2024 Prior Authorization Matrix - Effective 1/1/2024
2023 Prior Authorization Guide - Medicaid - Effective 10/1/23
2023 Prior Authorization Matrix - Effective 10/1/23
2023 Prior Authorization Guide - Marketplace - Effective 10/1/23
2023 Prior Authorization Guide - Medicaid - Effective 7/1/23
2023 Prior Authorization Matrix - Effective 7/1/23
2023 Prior Authorization Matrix - Effective 4/1/23
Q1 2023 PA Matrix including NCH Cardiology Management Program - Effective 3/1/2023
2023 Prior Authorization Guide - Effective 1/1/23
2023 Prior Authorization Guide - Medicare - Effective 1/1/23
2023 Prior Authorization Matrix - Effective 1/1/23
2022 Prior Authorization Guide - Effective 10/01/2022
2022 Prior Authorization Matrix - Effective 10/01/2022
2022 Prior Authorization Guide - Effective 07/01/2022
2022 Prior Authorization Guide - Medicare - Effective 07/01/2022
2022 Prior Authorization Matrix - Effective 07/01/2022
2022 Prior Authorization Guide - Effective 04/01/2022 
2022 Prior Authorization Guide - Medicare - Effective 04/01/2022 
2022 Prior Authorization Matrix - Effective 04/01/2022
2022 Prior Authorization Guide - Effective 01/01/2022
2022 Prior Authorization Guide - Medicare - Effective 01/01/2022
2022 Prior Authorization Matrix - Effective 01/01/2022
2021 Prior Authorization Guide - Effective 10/01/2021
2021 Prior Authorization Guide - Medicare - Effective 10/01/2021
2021 Prior Authorization Matrix - Effective 10/01/2021
2021 Prior Authorization Guide - Effective 07/01/2021 
2021 Prior Authorization Guide - Medicare - Effective 07/01/2021 
2021 Prior Authorization Matrix - Effective 07/01/2021 

Prior Authorization Forms
Alternate Level of Care Request Form
Behavioral Health Request Form

MI Medicaid Synagis Authorization Form

Drug Prior Authorization Form

MI-Alternative Level of Care Authorization Form

Prior Authorization Form