Prior Authorization for Services

SummaCare utilizes one prior authorization list for all fully-insured PPO health insurance plans and Medicare plans. Please use the forms below when requesting prior authorization for these services. These forms include the information which is necessary for a prior authorization determination. 

Please note: More information may be requested upon your completion and submission of the applicable form(s).

Applicable to requests submitted via Plan Central for Commercial and Marketplace plans: Determinations and responses for requests submitted electronically will be made within 48 hours for urgent requests and 10 calendar days for non-urgent requests from the time the request is received by SummaCare with all information necessary to support the prior authorization request.

To view prior authorization lists for self-funded groups, please visit Plan Central and click on "Related Documents" after logging in.