Authorization basics for providers

Determine if medical authorization is required for a Commercial/FEP PPO member

AuthAccel can tell you when a medical authorization is not required for a Blue Shield Commercial/FEP member or if it is delegated to another approver. Note, behavioral health falls under the medical benefit. When either is the case, completing and submitting the request in AuthAccel will result in an inquiry. You must complete the process and click the Submit button to secure an inquiry number. You can download and/or print the inquiry for your records. When medical authorization is required by Blue Shield, you can complete and submit the request in AuthAccel. Please see the request a medical authorization (PDF, 329 KB) instructions for additional detail.

You can also view Blue Shield’s prior authorization list or contact Blue Shield of California Provider Services to determine if medical authorization is required.

Determine if medical authorization is required for a Medicare or Medi-Cal member

While you can submit an authorization in AuthAccel for a Medicare or Medi-Cal member, the system cannot tell you if the request is required or delegated. 

To determine if medical authorization is required for a Medicare member, please consult the prior authorization list or call Blue Shield of California Provider Services at (800) 541-6652. Note, behavioral health falls under the medical benefit.

To determine if medical authorization is required for a Medi-Cal member, please consult the Prior Authorization Code Lists located on the prior authorization list page, or call Blue Shield Promise Health Plan at (800) 468-9935.

Submit a medical authorization request and check status for all plan types

Medical authorizations for Blue Shield of California and Blue Shield Promise Health Plan members, including requests for behavioral health services, can be submitted online in AuthAccel. Medical authorization status can also be viewed online, regardless of how the request is submitted. Detailed instructions for how to submit medical authorizations and check their status in AuthAccel are available from the links above as well as from the AuthAccel online authorization training page.

Additionally, medical authorization requests for Commercial/FEP PPO and Medicare members can be faxed, and in some cases, phoned in. To obtain a fax form, visit the prior authorization forms page. For telephone contacts, please see the Blue Shield of California Member Authorizations section on the Authorization contacts page. 

Medi-Cal medical authorization requests can also be faxed, and in some cases, phoned in. To obtain a fax form, visit the Provider forms page. For telephone contacts, please see the Blue Shield Promise Member Authorizations section on the Authorization contacts page.

Determine if pharmacy authorization is required for a Commercial member or Medicare member

To determine if pharmacy authorization is required, navigate to the Blue Shield outpatient drug formulary page and select the Blue Shield of California IFP, Small Group, Large Group, and Medicare formularies link. 

• For Commercial members, scroll to either the Individual and Family Plan/Small Group section or the Large Group section, then click the appropriate plan’s drug formulary link.
• For Medicare members, click the Medicare Part D prescription drug formularies link, then select the appropriate plan. 
• All formularies allow search by drug name and by therapeutic class. Once you search for and locate a drug:
  • The drug details screen will display with a legend that defines the symbols used in the online formulary. To collapse this legend, click the down arrow.
  • The symbol “PA” means that prior authorization is required.

For drug formulary information for Commercial and Medicare member outpatient prescription drugs and home self-administered injectables, call (800) 535-9481.

Submit a pharmacy authorization for a FEP PPO member or check if one is required

CVS Caremark is the program administrator for FEP PPO member retail drugs and is responsible for assisting with prior authorization. Visit the Blue Cross Blue Shield Federal Employee Program Prescription Drugs page for formulary information and approval forms or call a number below:

• Retail Pharmacy Program: (800) 624-5060, [TTY: (800) 624-5077]
• Specialty Drug Pharmacy Program: (888) 346-3731, [TTY: (877) 853-9549]

Submit a pharmacy authorization for a Commercial or Medicare member and check status

Blue Shield providers that utilize the Surescripts® or CoverMyMeds® EHR platforms and have electronic prior authorization (ePA) functionality enabled on their systems, can submit ePA for their patients to request outpatient drug prior authorization. This capability provides a real-time response for drug authorizations at point of care. ePA can also identify drugs that do not require prior authorization and eliminate the need to complete and submit paper forms. Additionally, providers can access CoverMyMeds from this website.

Pharmacy authorizations for Commercial and Medicare members can also be submitted online in AuthAccel. Pharmacy authorization status can be viewed online for these members, regardless of how the request is submitted. Detailed instructions for how to submit pharmacy authorizations and check their status in AuthAccel are available from the links above as well as from the AuthAccel online authorization training page.

Pharmacy authorization requests for Commercial and Medicare members can also be faxed to Blue Shield. Please see the Prescription drug prior authorization and step therapy exception request forms section on the prior authorization forms page.

For drug formulary information and to request prior authorization for Commercial and Medicare member outpatient prescription drugs and home self-administered injectables, call (800) 535-9481.