What is prior authorization and when is it needed?
Certain medications and medical services need to be approved by Blue Shield of California before they will be covered. This is called a prior authorization. This helps make sure the drug or service is safe and necessary for your care. Your doctor or provider usually makes this request for you.
Without this pre-approval, Blue Shield may not help pay for your medication or medical service, and you will have to pay out of pocket.
How to check for coverage
Not everything requires prior authorization. There’s a relatively easy way to check for both prescription drugs and medical services.
Prescription drugs
There are two ways to check which drugs are covered by your plan.
- Check the list of covered drugs, also known as the drug formulary.
- Log in and go to the Pharmacy benefits page. There you'll find the Price Check My Rx tool. Use Price Check My Rx to determine coverage by looking at the pricing and possible alternatives. This tool can be more helpful than looking at a formulary list.
Medical services
To see if a medical service needs prior authorization, open the Blue Shield prior authorization list. If your service is on the list, work with your doctor to request prior authorization. You may also need to reference Blue Shield’s medical policy list.
For any coverage questions, you can also call Customer Service at the number on your Blue Shield member ID card.
Who starts the prior authorization process?
Usually, your doctor usually starts the process by submitting a request on your behalf. It includes details about your diagnosis and why a specific prescription drug, medical service, or surgery is needed. To submit a requestion, your doctor may complete the Prior Authorization Request form and fax it to (888) 697-8122.
If you are unsure whether the process has begun, contact your doctor’s office directly to confirm a prior authorization request was submitted. Medicare members may also call Customer Service at the number on their member ID card.
Commercial members
You can submit a request on your own. Find the appropriate prescription drug or medical procedure authorization form for your situation. Or log into your account on the website and complete the request online.
Medicare members
Your healthcare provider, authorized representative, or you may submit a prior authorization request by one of the same methods as a commercial member, or by calling (800) 535-9481.
Federal Employee Program members
Members of the Federal Employee Blue Cross Blue Shield Service Benefit Plan (FEP) may have different requirements. Call Customer Service at the number on your member ID card.
How long does the prior authorization process take?
It typically takes 24 to 72 hours.
You may check the status of your prior authorization request on the prior authorizations page. You may also contact your doctor’s office directly.
For any questions, call the Customer Service number on your Blue Shield member ID card.
Y0118_24_623A_C 09202024
H2819_24_623A_C Accepted 09302024
Page last updated: 10/01/2024
This information is not a complete description of benefits.
1Specialty medications and opioids are limited to a 30-day supply.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
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For Blue Shield Medicare Advantage Plans: Blue Shield of California is an HMO, HMO D-SNP, PPO and a PDP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.
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