Preauthorization Forms and Lists 

Online Preauthorization Requests

Preauthorization requests should primarily be submitted via Select Health’s online tools.
Submit medical preauthorization
Submit pharmacy preauthorization

Manual Preauthorization forms

In some cases, a paper preauthorization form can be submitted. Please note that paper preauthorization request will take more time to be processed.
Request for Medical Preauthorization
Submit pharmacy preauthorization

Non-Covered & Preauth Code Lists

Access non-covered codes or those covered with preauthorization requirements by state and plan type*:

Commercial Plans Non-Covered Code Lists

Utah

Colorado 

Idaho

Nevada

Medicare Plans Non-Covered Code Lists

Utah

Colorado

Idaho

Nevada 

Medicaid Plans Non-Covered Code Lists

Utah Only

 

Download Using Online Covered-Codes Files for tips on quickly searching for the information you need.

*This information is updated quarterly and subject to plan specifics. For current preauthorization lists, please review the applicable certificate of coverage. For questions, contact Member Services at 800-538-5038.