How does the drug prior authorization process work?
If you need a prescription drug that is not covered by your outpatient prescription drug benefit, your physician or an authorized member of his or her staff may submit for prior authorization from Blue Shield.
For a prior authorization request to be considered for approval, a doctor would need to provide some clinical information about you such as your diagnosis, or medical reason why the preferred alternative(s) would not be appropriate for you.
The Blue Shield Pharmacy and Therapeutics Committee selects the drugs that require prior authorization and develops the coverage criteria for any drugs that require prior authorization.
Your physician or pharmacy may visit blueshieldca.com/provider and select “Request Authorization” from within the authorization section of the site. They will then be guided to the Provider login screen granting access to request prior authorization via the web.
Providers also have the option to complete and fax the California standard Prescription Drug Prior Authorization Request Form to (888) 697-8122. Prior authorizations for the commercial plans are not accepted via phone.
Your physician or pharmacist may submit a prior authorization via one of the methods listed above or via phone to (800)-535-9481 Monday through Friday, 8:00 a.m. until 6:00 p.m. PST, excluding holidays.
As the patient, can I begin the process to request prior authorization?
Yes, you may begin the process to obtain prior authorization, including requests for medically necessary nonformulary prescription drugs; however, your physician or an authorized member of his or her staff may be required to provide supporting medical documentation. Your physician can contact Blue Shield's Pharmacy Services to request a prior authorization on your behalf, or you may .
How long is the review process?
A prior authorization decision may take up to 24 to 72 hours.
How do I check the status of a prior authorization request?
You can call the Member Services phone number on your member ID card from 7 a.m. to 7 p.m. Pacific time, Monday through Friday, or you can call your doctor's office.