What's prior authorization and how does it work?

Who is this for?

Learn more about prescription drug and pharmacy coverage.

If your pharmacist said your prescription drug needs our approval, this explains why and what your options are.

When your doctor prescribes a medication, you trust it's the right one for you. That's not always the case. And that's why we have programs like prior authorization. When we review certain drugs before your plan covers them, it helps make sure you're getting the right medication for the right situation.

Why would a drug need prior authorization?

Here are some of the reasons we require prior authorization for a drug:

  • The drug has dangerous side effects or can be harmful when combined with other drugs.
  • The drug should be used only for certain health conditions.
  • The drug is often misused or abused.
  • There are less expensive drugs that might work better.
  • To determine whether the drug is covered by Medicare Part B or Part D.

What if my prescription requires prior authorization?

First, you or your pharmacist should talk to your doctor. There may be another drug you can take that doesn't need prior authorization. If not, you can start the approval process by calling the number on the back of your Blue Cross ID card.

You can also start the approval process by filling out and sending in a coverage determination form.

How do I know if a prescription requires prior authorization?

You can use your plan's drug list, also called a formulary. Start by finding your plan here. Then look for a PA after the name of your prescription. You might find this article helpful: How do I read a drug list?