New Prior Authorization (PA) Forms

Date: 01/02/26

Effective January 1, 2026, Ambetter Health will update its Prior Authorization Forms.

Forms being discontinued:

• Outpatient Authorization Form
• Inpatient Authorization Form
• Prior Authorization Request Form for Non-Specialty Drugs

New forms available:

• Nebraska Standard Prior Authorization Request Form for HealthCare Services
  Replaces: Outpatient Authorization Form, Inpatient Authorization Form
• Nebraska Standard Prior Authorization Request Form for Prescription Drug Benefits/DME
  Replaces: Outpatient Authorization Form (DME only), Prior Authorization Request Form for Non-Specialty Drugs

You can access the updated forms in the Provider Resources section.

Thank you for your partnership in delivering quality care and improving health outcomes.

For questions, please contact Provider Services.