Prior authorization

Prior Authorization (PA) Grid and Drug Formulary

• Medical Covered Services Prior Authorization Grid
• Medical Benefit Drug Prior Authorization Grid
• Durable Medical Equipment List – Specialty Devices
• Durable Medical Equipment List – Brands
• Drug Prior Authorization Requirements – Medi-Cal (Formulary)
• Drug Prior Authorization Requirements - Cal MediConnect (Formulary)

Prior Authorization Request Forms

• Prior Authorization Request – Medical Services
• Prior Authorization Request – Prescription Drug
• Prior Authorization Request – Prescription Drug (Part D)
• Prior Authorization Request – Transportation

Managed Long Term Services and Support

• Long-Term Care – Authorization Form and FAQs
• Bed Hold Authorization Request Form
• Long-Term Care – Discharge Notification Form

Referral Forms

• Referral Form – Case Management
• Referral Form – Health Homes