2025 Part D Prior Authorization Criteria

Look up your plan below to find your prior authorization criteria.

Alabama

• Devoted CHOICE GIVEBACK Alabama (PPO)
• All other Alabama plans

Arizona

• Devoted EXTRA Arizona (HMO) and Devoted PRIME Arizona (HMO)
• Devoted CHOICE Arizona (PPO) – Cochise, Coconino, Graham, La Paz, Pima, Santa Cruz, Yavapai, and Yuma counties
• Devoted CHOICE Arizona (PPO) – Maricopa and Pinal counties
• All other Arizona plans

Arkansas

• All Arkansas plans

Colorado

• All Colorado plans

Florida

• Devoted EXTRA Florida (HMO) and Devoted CHOICE GIVEBACK Florida (PPO) – all counties except Pensacola
• All other Florida plans

Georgia

• All Georgia plans

Hawaii

• Maui and Hawaii counties
• Honolulu and Kauai counties

Illinois

• All Illinois plans

Indiana

• All Indiana plans

Kentucky

• All Kentucky plans

Mississippi

• All Mississippi plans

Missouri

• All Missouri plans

North Carolina

• Devoted CHOICE North Carolina (PPO) and Devoted CHOICE GIVEBACK North Carolina (PPO)
• All other North Carolina plans

Ohio

• Devoted CHOICE EXTRA Ohio (PPO)
• All plans except Devoted CHOICE EXTRA Ohio (PPO)

Oregon

• Devoted GIVEBACK Oregon (HMO) and Devoted PREMIUM Oregon (HMO)
• Devoted CORE Oregon (HMO) – Clackamas, Columbia, Multnomah, and Washington counties
• Devoted CORE Oregon (HMO) – Lane, Lincoln, and Linn counties
• Devoted CHOICE Oregon (PPO) and Devoted CHOICE PLUS Oregon (PPO)

Pennsylvania

• Devoted CHOICE Pennsylvania (PPO) and Devoted CHOICE GIVEBACK Pennsylvania (PPO) – Berks, Bucks, Chester, Delaware, Lehigh, Montgomery, Northampton, and Philadelphia counties
• Devoted CHOICE Pennsylvania (PPO) and Devoted CHOICE GIVEBACK Pennsylvania (PPO) – Armstrong, Bedford, Blair, Carbon, Clarion, Clearfield, Clinton, Crawford, Elk, Forest, Fulton, Huntingdon, Jefferson, Lackawanna, Lawrence, Luzerne, Monroe, Somerset, Susquehanna, and Wyoming counties
• Devoted DUAL PLUS Pennsylvania (HMO D-SNP)
• Devoted CHOICE PLUS Pennsylvania (PPO), Devoted CORE Pennsylvania (HMO), and Devoted GIVEBACK Pennsylvania (HMO)

South Carolina

• Devoted PREMIUM South Carolina (HMO)
• All other South Carolina plans

Tennessee

• Devoted CHOICE Tennessee (PPO) and Devoted CHOICE GIVEBACK Tennessee (PPO) – Fayette, Hardeman, Haywood, and Shelby counties
• Devoted CHOICE Tennessee (PPO) and Devoted CHOICE GIVEBACK Tennessee (PPO) – all counties except Fayette, Hardeman, Haywood, and Shelby
• Devoted BE WELL PLUS Tennessee (HMO C-SNP), Devoted CORE Tennessee (HMO), and Devoted GIVEBACK Tennessee (HMO)

Texas

• Devoted CORE Austin (HMO), DUAL PLUS Plans, Devoted EXTRA Greater Houston (HMO), and Devoted GIVEBACK San Antonio (HMO)
• All other Texas plans

Washington

• All Washington plans