- prescription drugs
- drug coverage limits
- 2027 Part D Prior Authorization Criteria
2027 Part D Prior Authorization Criteria
Look up your plan below to find your prior authorization criteria.
Alabama
- DEVOTED C-SNP CHOICE 008 AL (PPO C-SNP), DEVOTED C-SNP CHOICE 010 AL (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 017 AL (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 018 AL (PPO C-SNP), DEVOTED CHOICE GIVEBACK EXTRAS 038 AL (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 039 AL (PPO)
- All other Alabama plans
Arizona
- DEVOTED C-SNP 023 AZ (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 102 AZ (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 103 AZ (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 104 AZ (HMO C-SNP), DEVOTED CHOICE 001 AZ (PPO), DEVOTED CORE 090 AZ (HMO), DEVOTED GIVEBACK EXTRAS 105 AZ (HMO), DEVOTED GIVEBACK EXTRAS 106 AZ (HMO), and DEVOTED GIVEBACK EXTRAS 107 AZ (HMO)
- All other Arizona plans
Arkansas
- DEVOTED C-SNP CHOICE 006 AR (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 011 AR (PPO C-SNP), DEVOTED CHOICE 001 AR (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 012 AR (PPO)
- All other Arkansas plans
Colorado
- DEVOTED C-SNP GIVEBACK EXTRAS 016 CO (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 017 CO (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 018 CO (HMO C-SNP), DEVOTED CHOICE 005 CO (PPO), DEVOTED CORE 014 CO (HMO), DEVOTED GIVEBACK EXTRAS 019 CO (HMO), DEVOTED GIVEBACK EXTRAS 020 CO (HMO), and DEVOTED GIVEBACK EXTRAS 021 CO (HMO)
- All other Colorado plans
Connecticut
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 005 CT (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 014 CT (PPO C-SNP), DEVOTED CHOICE 001 CT (PPO), DEVOTED CHOICE 010 CT (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 009 CT (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 018 CT (PPO)
- All other Connecticut plans
Delaware
- DEVOTED C-SNP CHOICE PLUS 003 DE (PPO C-SNP) and DEVOTED CHOICE GIVEBACK 002 DE (PPO)
- All other Delaware plans
Florida
- DEVOTED CHOICE GIVEBACK EXTRAS 017 FL (PPO), DEVOTED CORE 057 FL (HMO), DEVOTED CORE 058 FL (HMO), DEVOTED CORE 059 FL (HMO), DEVOTED CORE 060 FL (HMO), DEVOTED CORE 061 FL (HMO), DEVOTED CORE 063 FL (HMO), DEVOTED CORE 064 FL (HMO), DEVOTED CORE 065 FL (HMO), DEVOTED CORE 066 FL (HMO), DEVOTED CORE 092 FL (HMO), DEVOTED GIVEBACK EXTRAS 105 FL (HMO), DEVOTED GIVEBACK EXTRAS 106 FL (HMO), DEVOTED GIVEBACK EXTRAS 107 FL (HMO), DEVOTED GIVEBACK EXTRAS 108 FL (HMO), DEVOTED GIVEBACK EXTRAS 109 FL (HMO), DEVOTED GIVEBACK EXTRAS 110 FL (HMO), DEVOTED GIVEBACK EXTRAS 112 FL (HMO), DEVOTED GIVEBACK EXTRAS 113 FL (HMO), DEVOTED GIVEBACK EXTRAS 114 FL (HMO), DEVOTED GIVEBACK EXTRAS 115 FL (HMO), DEVOTED GIVEBACK EXTRAS 116 FL (HMO), and DEVOTED GIVEBACK EXTRAS 117 FL (HMO)
- All other Florida plans
Georgia
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 019 GA (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 020 GA (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 021 GA (PPO C-SNP), DEVOTED CHOICE 004 GA (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 022 GA (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 023 GA (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 024 GA (PPO)
- All other Georgia plans
Hawaii
- DEVOTED C-SNP GIVEBACK EXTRAS 006 HI (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 007 HI (HMO C-SNP), DEVOTED CHOICE PREMIUM 010 HI (PPO), DEVOTED CORE 004 HI (HMO), DEVOTED CORE 005 HI (HMO), DEVOTED GIVEBACK EXTRAS 008 HI (HMO), and DEVOTED GIVEBACK EXTRAS 009 HI (HMO)
- All other Hawaii plans
Illinois
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 015 IL (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 016 IL (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 017 IL (PPO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 007 IL (HMO C-SNP), DEVOTED CHOICE 001 IL (PPO)DEVOTED CHOICE 003 IL (PPO), DEVOTED CHOICE 010 IL (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 018 IL (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 019 IL (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 020 IL (PPO), DEVOTED CORE 001 IL (HMO), and DEVOTED GIVEBACK EXTRAS 008 IL (HMO)
- All other Illinois plans
Indiana
- DEVOTED C-SNP CHOICE ENHANCED 014 IN (PPO C-SNP), DEVOTED C-SNP CHOICE ENHANCED 015 IN (PPO C-SNP), DEVOTED C-SNP CHOICE ENHANCED 016 IN (PPO C-SNP), DEVOTED C-SNP CHOICE ENHANCED 017 IN (PPO C-SNP), DEVOTED C-SNP CHOICE PLUS 013 IN (PPO C-SNP), DEVOTED CHOICE 005 IN (PPO), DEVOTED CHOICE GIVEBACK 002 IN (PPO), DEVOTED CHOICE GIVEBACK 006 IN (PPO), DEVOTED CHOICE GIVEBACK 009 IN (PPO), and DEVOTED CHOICE GIVEBACK 012 IN (PPO)
- All other Indiana plans
Iowa
Kansas
- DEVOTED C-SNP CHOICE ENHANCED 003 KS (PPO C-SNP), DEVOTED C-SNP CHOICE ENHANCED 007 KS (PPO C-SNP), DEVOTED C-SNP CHOICE PLUS 004 KS (PPO C-SNP), DEVOTED CHOICE GIVEBACK 002 KS (PPO), and DEVOTED CHOICE GIVEBACK 006 KS (PPO)
- All other Kansas plans
Kentucky
- DEVOTED C-SNP CHOICE ENHANCED 005 KY (PPO C-SNP), DEVOTED C-SNP CHOICE ENHANCED 006 KY (PPO C-SNP), DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP), and DEVOTED CHOICE GIVEBACK 002 KY (PPO)
- All other Kentucky plans
Louisiana
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 019 LA (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 020 LA (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 021 LA (PPO C-SNP), DEVOTED CHOICE 001 LA (PPO), DEVOTED CHOICE 005 LA (PPO), DEVOTED CHOICE 016 LA (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 027 LA (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 028 LA (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 029 LA (PPO)
- All other Louisiana Plans
Michigan
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 007 MI (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 009 MI (PPO C-SNP), DEVOTED CHOICE 001 MI (PPO), DEVOTED CHOICE 005 MI (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 015 MI (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 017 MI (PPO)
- All other Michigan plans
Mississippi
- DEVOTED C-SNP CHOICE 006 MS (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 011 MS (PPO C-SNP), DEVOTED CHOICE 001 MS (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 012 MS (PPO)
- All other Mississippi plans
Missouri
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 026 MO (PPO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 017 MO (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 018 MO (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 021 MO (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 029 MO (HMO C-SNP), DEVOTED CHOICE 001 MO (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 005 MO (PPO), DEVOTED CORE 003 MO (HMO), DEVOTED CORE 009 MO (HMO), DEVOTED CORE 023 MO (HMO), DEVOTED GIVEBACK EXTRAS 024 MO (HMO), DEVOTED GIVEBACK EXTRAS 025 MO (HMO), DEVOTED GIVEBACK EXTRAS 026 MO (HMO), and DEVOTED GIVEBACK EXTRAS 028 MO (HMO)
- All other Missouri plans
Nebraska
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 010 NE (PPO C-SNP), DEVOTED CHOICE 001 NE (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 011 NE (PPO)
- All other Nebraska plans
New Hampshire
- DEVOTED C-SNP CHOICE PLUS 003 NH (PPO C-SNP) and DEVOTED CHOICE GIVEBACK 002 NH (PPO)
- All other New Hampshire plans
New Jersey
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 005 NJ (PPO C-SNP) and DEVOTED CHOICE GIVEBACK EXTRAS 006 NJ (PPO)
- All other New Jersey plans
New Mexico
- DEVOTED C-SNP ENHANCED 003 NM (HMO C-SNP), DEVOTED C-SNP ENHANCED 007 NM (HMO C-SNP), DEVOTED C-SNP PLUS 004 NM (HMO C-SNP), DEVOTED GIVEBACK 002 NM (HMO), and DEVOTED GIVEBACK 006 NM (HMO)
- All other New Mexico plans
New York
- DEVOTED CHOICE GIVEBACK (PPO), DEVOTED C-SNP CHOICE ENHANCED (PPO C-SNP), and DEVOTED C-SNP CHOICE PLUS (PPO C-SNP)
- DEVOTED CHOICE (PPO) DEVOTED CHOICE GIVEBACK EXTRAS (PPO C-SNP), and DEVOTED C-SNP CHOICE GIVEBACK EXTRAS (PPO C-SNP)
North Carolina
- DEVOTED C-SNP GIVEBACK EXTRAS 031 NC (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 032 NC (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 033 NC (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 034 NC (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 045 NC (HMO C-SNP), DEVOTED CHOICE 003 NC (PPO), DEVOTED CHOICE 008 NC (PPO), DEVOTED CORE 021 NC (HMO), DEVOTED CORE 023 NC (HMO), DEVOTED CORE 029 NC (HMO), DEVOTED CORE 037 NC (HMO), DEVOTED GIVEBACK EXTRAS 038 NC (HMO), DEVOTED GIVEBACK EXTRAS 039 NC (HMO), DEVOTED GIVEBACK EXTRAS 041 NC (HMO), DEVOTED GIVEBACK EXTRAS 042 NC (HMO), and DEVOTED GIVEBACK EXTRAS 044 NC (HMO)
- All other North Carolina plans
Ohio
- DEVOTED C-SNP GIVEBACK EXTRAS 023 OH (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 024 OH (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 025 OH (HMO C-SNP), DEVOTED CHOICE 003 OH (PPO), DEVOTED CORE 015 OH (HMO), DEVOTED CORE 019 OH (HMO), DEVOTED CORE 022 OH (HMO), DEVOTED GIVEBACK EXTRAS 026 OH (HMO), DEVOTED GIVEBACK EXTRAS 027 OH (HMO), and DEVOTED GIVEBACK EXTRAS 028 OH (HMO)
- All other Ohio plans
Oklahoma
- DEVOTED CHOICE (PPO), DEVOTED CHOICE GIVEBACK EXTRAS (PPO), and DEVOTED C-SNP CHOICE GIVEBACK EXTRAS (PPO C-SNP)
- DEVOTED CHOICE GIVEBACK (PPO), DEVOTED C-SNP CHOICE ENHANCED (PPO C-SNP), DEVOTED C-SNP CHOICE PLUS (PPO C-SNP), and DEVOTED DUAL CHOICE FULL (PPO D-SNP)
Oregon
- DEVOTED C-SNP ENHANCED 013 OR (HMO C-SNP), DEVOTED C-SNP PLUS 009 OR (HMO C-SNP), DEVOTED C-SNP PLUS 014 OR (HMO C-SNP), DEVOTED CHOICE PREMIUM 002 OR (PPO), DEVOTED CORE 001 OR (HMO), DEVOTED CORE 026 OR (HMO), DEVOTED GIVEBACK 012 OR (HMO), and DEVOTED GIVEBACK 028 OR (HMO)
- All other Oregon plans
Pennsylvania
- DEVOTED C-SNP GIVEBACK EXTRAS 027 PA (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 028 PA (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 029 PA (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 030 PA (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 031 PA (HMO C-SNP), DEVOTED CHOICE 007 PA (PPO), DEVOTED CORE 008 PA (HMO), DEVOTED CORE 010 PA (HMO), DEVOTED CORE 012 PA (HMO), DEVOTED CORE 014 PA (HMO), DEVOTED GIVEBACK EXTRAS 032 PA (HMO), DEVOTED GIVEBACK EXTRAS 033 PA (HMO), DEVOTED GIVEBACK EXTRAS 034 PA (HMO), DEVOTED GIVEBACK EXTRAS 035 PA (HMO), and DEVOTED GIVEBACK EXTRAS 036 PA (HMO)
- All other Pennsylvania plans
South Carolina
- DEVOTED C-SNP CHOICE 004 SC (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 045 SC (PPO C-SNP), and DEVOTED CHOICE GIVEBACK EXTRAS 040 SC (PPO)
- All other South Carolina plans
Tennessee
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 032 TN (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 034 TN (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 035 TN (PPO C-SNP), DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 036 TN (PPO C-SNP), DEVOTED CHOICE 024 TN (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 041 TN (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 042 TN (PPO), DEVOTED CHOICE GIVEBACK EXTRAS 043 TN (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 044 TN (PPO)
- All other Tennessee plans
Texas
- DEVOTED C-SNP 027 TX (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 082 TX (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 083 TX (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 085 TX (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 086 TX (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 087 TX (HMO C-SNP), DEVOTED C-SNP GIVEBACK EXTRAS 089 TX (HMO C-SNP), DEVOTED CORE 001 TX (HMO), DEVOTED CORE 019 TX (HMO), DEVOTED CORE 067 TX (HMO), DEVOTED CORE 073 TX (HMO), DEVOTED GIVEBACK EXTRAS 109 TX (HMO), DEVOTED GIVEBACK EXTRAS 110 TX (HMO), DEVOTED GIVEBACK EXTRAS 112 TX (HMO), DEVOTED GIVEBACK EXTRAS 113 TX (HMO), DEVOTED GIVEBACK EXTRAS 114 TX (HMO), DEVOTED GIVEBACK EXTRAS 116 TX (HMO), and DEVOTED PREMIUM 002 TX (HMO)
- All other Texas plans
Utah
- DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 011 UT (PPO C-SNP), DEVOTED CHOICE 001 UT (PPO), and DEVOTED CHOICE GIVEBACK EXTRAS 014 UT (PPO)
- All other Utah plans
Virginia
- DEVOTED C-SNP ENHANCED (HMO C-SNP), DEVOTED C-SNP PLUS (HMO C-SNP), and DEVOTED GIVEBACK (HMO)
- DEVOTED CORE (HMO), DEVOTED C-SNP GIVEBACK EXTRAS (HMO C-SNP), and DEVOTED GIVEBACK EXTRAS (HMO)