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.
Commercial plans:
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.
Medicare plans:
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?
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.
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.
You may begin the process to obtain a drug prior authorization, or your physician can contact Blue Shield's Pharmacy Services to request one on your behalf.
Y0118_22_513A_C 09152022
Page last updated: 10/01/2022
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Blue Shield of California is an HMO and PDP plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal.
This information is not a complete description of benefits. Call Member Services at (800) 776-4466 [TTY: 711] for more information.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
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