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What's prior authorization and how does it work?

Who is this for?

Learn more about prescription drug and pharmacy coverage.

If your pharmacist said your prescription drug needs our approval, this explains why and what your options are.

When your doctor prescribes a medication, you trust it's the right one for you. That's not always the case. And that's why we have programs like prior authorization. When we review certain drugs before your plan covers them, it helps make sure you're getting the right medication for the right situation.

Why would a drug need prior authorization?

Here are some of the reasons we require prior authorization for a drug:

  • The drug has dangerous side effects or can be harmful when combined with other drugs.
  • The drug should be used only for certain health conditions.
  • The drug is often misused or abused.
  • There are less expensive drugs that might work better.
  • To determine whether the drug is covered by Medicare Part B or Part D.

What if my prescription requires prior authorization?

First, you or your pharmacist should talk to your doctor. There may be another drug you can take that doesn't need prior authorization. If not, your doctor can start the approval process by calling our Pharmacy Help Desk.

You can also start the approval process yourself by filling out and sending in a coverage determination form.

How do I know if a prescription requires prior authorization?

You can use your plan's drug list, also called a formulary. Start by finding your plan below. Then look for a PA after the name of your prescription. You might find this article helpful: How do I read a drug list?

Tip: You can quickly find your drug in a PDF using these shortcuts. For Windows, type Ctrl+F. If you're a Mac user, type Command+F. A small window will pop up on the screen. Enter the drug you’re looking for, and you'll see all the places it shows up.

Individual Plans Drug List / Formulary
Medicare Plus Blue℠ PPO plans:
Essential, Vitality and Signature

Prescription Blue℠ PDP Option A
Comprehensive Formulary (PDF)

Want more details?
Prior Authorization Criteria (PDF)

Medicare Plus Blue PPO Assure

Prescription Blue PDP Option B
Comprehensive Formulary (PDF)

Want more details?
Prior Authorization Criteria (PDF)
BCN Advantage℠ HMO and
HMO-POS plans

Comprehensive Formulary (PDF)

Want more details?
Prior Authorization Criteria (PDF)

Group Plans
Drug List / Formulary
Medicare Plus Blue Group PPO

Prescription Blue Group PDP
Group Comprehensive Formulary (PDF)

Group Enhanced Comprehensive Formulary (PDF)

Want more details?
Prior Authorization Criteria (PDF)
Medicare Plus Blue Group PPO:
Essential, Vitality and Signature plans
Comprehensive Formulary (PDF)

Want more details?
Prior Authorization Criteria (PDF)
Medicare Plus Blue Group PPO Assure
Comprehensive Formulary (PDF)

Want more details?
Prior Authorization Criteria (PDF)
BCN Advantage HMO-POS for Groups

Comprehensive Formulary (PDF)

Want more details?
Prior Authorization Criteria (PDF)

Not sure what group plan you have or which drug list to use? Don't see yours listed here? Call the Customer Service number on the back of your Blues ID card and we'll help.

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Page Last Updated Thu Jul 03 11:39:49 EDT 2014