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Drug Prior Authorization

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    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 Pharmacist may call or fax Blue Shield of California Pharmacy Services to request a prior authorization at the following times:

    • Commercial Plans 8 a.m. to 5 p.m. Monday, Wednesday, Thursday & Friday (Tuesday 8 a.m. to 4 p.m.)

    • Medicare Plans 8 a.m. to 6 p.m. Monday through Friday.

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    As the patient, can I begin the process to request prior authorization?

    Yes, you may begin the process to obtain prior authorization; however, your physician or an authorized member of his or her staff may be required to provide supporting medical documentation. If required, your physician can contact Blue Shield's Pharmacy Services to request prior authorization on your behalf.
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    How long is the review process?

    If your physician's office calls with all relevant medical information including member name, member ID number, diagnosis and past medication history, we may be able to provide a prior authorization decision during the call. If the request is faxed, it may take up to 24 to 72 hours for a decision.
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    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.

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