Providers

Prior Authorizations

Certain services, items and prescriptions for some injectable or infusion drugs must be pre-approved. Prior Authorizations are also sometimes referred to as “preauthorizations” or “precertifications.”

2026 Medicaid/CHIP Prior Authorizations 2026 Medicare Prior Authorizations 2026 Individual and Family Plans Prior Authorizations

Prior Authorization Drug Lists

Below are detailed lists of medical drugs that require prior authorization and the area responsible for the prior authorization review.

Medical Prior Authorization Guidelines

Our prior authorization guidelines provide an up-to-date list of all services requiring prior authorization. Prior authorizations are processed either through our provider portal or eviCore. Check out our prior authorization management tool to identify which services require submission through the provider portal or eviCore:

Pharmacy Prior Authorization Request Forms

Pharmacy Prior Authorizations for both formulary and non-formulary pharmacy drugs can now be completed online. You may also continue to use the appropriate forms listed below.

Health Partners Plans Medicaid and CHIP

Pharmacy 2026 Drug-Specific Prior Authorization Forms — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
Pharmacy 2025 Drug-Specific Prior Authorization Forms — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
Pharmacy Non-Formulary Drug Prior Authorization Form — Use these request forms if the medication you want to request does not have an associated drug-specific form.

Fax all completed Medicaid and CHIP prior authorization request forms to the Pharmacy department at 1-866-240-3712.

Jefferson Health Plans Medicare Advantage

Pharmacy 2026 Drug-Specific Prior Authorization Forms — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
Pharmacy 2025 Drug-Specific Prior Authorization Forms — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
Pharmacy Prescription Drug Coverage Determination Request Form

Fax all completed Medicare Advantage prior authorization request forms to the Pharmacy department at 1-866-371-3239.

Jefferson Health Plans Individual and Family Plans

Pharmacy 2026 Drug-Specific Prior Authorization Form — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
Pharmacy 2025 Drug-Specific Prior Authorization Form — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
Pharmacy Non-Formulary Drug Prior Authorization Form — Use these request forms if the medication you want to request does not have an associated drug-specific form.

Fax all completed Individual and Family Plans Prior Authorization request forms to the Pharmacy department at 1-833-605-4407.

Frequently Asked Questions

Jefferson Health Plans requires prior authorizations for select services performed in an outpatient setting, including those performed in the office, short procedure units, ambulatory surgery centers, clinics and hospital outpatient departments.

Click here to view administrative, authorization and maternity care forms. You can also place supply requests from this page.

More information about denials can be found in the provider manual.

Prior Authorizations

Pharmacy Prior Authorization Request Forms

Health Partners Plans Medicaid and CHIP

Jefferson Health Plans Medicare Advantage

Jefferson Health Plans Individual and Family Plans

Do you require prior authorizations for outpatient services?

Where can I access forms and make supply requests?

What can I do if Jefferson Health Plans or Health Partners Plans denies a requested item or service?