Drug prior authorizations

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.

Commercial plans:

Your physician 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 use electronic prior authorization, or complete the California standard Prescription Drug Prior Authorization Request Form and fax to (888) 697-8122. Prior authorizations for the commercial plans are not accepted via phone.

Medicare plans:

You, your healthcare provider, or your authorized representative may submit a prior authorization via one of the methods listed above or via phone to (800)-535-9481 Monday through Friday, 8 a.m. to 6 p.m. Pacific time, excluding holidays.

You can call the Customer Service phone number on your member ID card from 7 a.m. to 7 p.m. Pacific time, Monday through Friday, call your doctor's office. to start a prior authorization, or you can initiate using the following link. Medicare members can call the Customer Service phone number on your member ID card from 8 a.m. to 8 p.m., seven days a week.

A prior authorization decision may take up to 24 to 72 hours.

You can call the Customer Service 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. Medicare members can call the Customer Service phone number on your member ID card from 8 a.m. to 8 p.m., seven days a week.