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).

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