Prior Authorization: What You Need to Know

In some cases, your doctor may need to get approval from us before your plan will cover certain health care services and medicines. This need is called prior authorization. Think this is a pain? It’s actually much easier than you think.

To help you get a better idea of how prior authorization works, we have answered some of the most frequently asked questions from members.

What is prior authorization?
“Prior authorization” refers to certain health care services and prescription drugs that will need to be approved by Blue Cross and Blue Shield of Texas (BCBSTX) before they are covered under your plan.  You may also hear it called “preauthorization”, “pre-certification” or “preapproval”.

Which health care services require prior authorization?
You can find out if a health care service needs pre-approval from BCBSTX by calling Customer Service at the number on the back of your member ID card.

What prescription drugs call for prior authorization?
You can find examples of drug categories and specific meds that may need preapproval on Prime Therapeutics’ website* under the “Find Medicine” tab. You can also get information on a specific medication by calling the Pharmacy Program phone number on the back of your BCBSIL member ID card.

What should I do if I find out that a drug or service needs prior authorization?
If you are seeing an in-network doctor, your doctor will need to submit a request for prior authorization. You may also want to follow up by calling the Customer Service number on your BCBSTX member ID card to make sure the prior authorization request was initiated.

If you are going to a doctor that is not in your plan’s network , you will personally have to directly contact us to get prior authorization. You can start the process by calling the Customer Service number on your BCBSTX member ID card.

What happens if I don’t get approval?
If coverage for the health care service or prescription drug is denied, you will be responsible for the full cost of that service or drug. You of course have the right to appeal any decisions made regarding prior authorization. Details about the appeals process can be found in your benefits documents.

Still have questions? No problem! Post them below or call the Customer Service number on your BCBSTX member ID card.

* Depending on your coverage, your prescription drug benefits may not be administered by Prime Therapeutics. If that’s the case call the Pharmacy Program number on the back of your member ID card to see if your medicine needs preapproval.

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