Some procedures, medical and surgical services, specific equipment, and select prescription drugs require prior authorization. A prior authorization is an approval review that Blue Shield of California Promise Health Plan conducts.
To request prior authorization for treatment or for a drug, you, your doctor, other prescriber, or appointed representative need to contact Blue Shield of California Promise Health Plan and provide necessary clinical information. If this information is not submitted, or does not meet the prior authorization criteria, the Health Plan may not cover the service or drug.
For a prior authorization request to be considered for approval, a doctor must provide clinical information which may include, but is not limited to, the following:
- Diagnosis or reason(s) you are receiving the drug treatment
- Lab test information (for example: LDL level for cholesterol treatment, or the hemoglobin A1C level for diabetes treatment)
- Your doctor's specialty
- Whether you have been evaluated by a specialist
- Other treatment(s) that have been attempted and whether they were effective
- Whether you experienced side effects from a particular treatment
- Required dosage and the estimated length of your expected treatment
- Whether a generic drug alternative may be medically appropriate for you
For assistance with a prior authorization request, please call Blue Shield Promise Cal MediConnect Plan Customer Care:
Phone: (855) 905-3825 [TTY: 711], 8 a.m. - 8 p.m., seven days a week
You may also contact Blue Shield Promise Cal MediConnect Plan Customer Care at the number listed above and ask to obtain the total number of the plan's grievances, appeals, and exceptions.
Part D Coverage Determination
Coverage determinations are decisions that Blue Shield Promise Cal MediConnect Plan makes about your coverage of prescription drugs.
You, your provider, or other prescriber can contact Customer Care at the number listed above to request a coverage determination. Your provider may use the optional Drug Coverage Form to submit their requests. However, this form is not necessary to request a coverage determination.
Physicians' Part D prescription coverage prior authorization form (PDF, 142 KB)