Why do I need prior authorization for a prescription drug?

Who is this for?

Michigan Health Insurance - Customer Service - Pharmacy

This information explains what it means if your doctor has prescribed a medication that needs prior authorization.

There are hundreds of different medications with more becoming available every day. Blue Cross Blue Shield of Michigan and Blue Care Network use prior authorization to make sure you get the right medication.

What is prior authorization?

This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. 

If you don’t get prior authorization, a medication may cost you more, or we may not cover it.

If you file an urgent request, we will have a decision provided in 72 hours or less. For an urgent review of a non-covered drug, one not on your drug list, we will have a decision in 24 hours or less. A standard request may take up to 15 days for us to make a decision.

What kinds of drugs need prior authorization?

  • Drugs that have dangerous side effects
  • Drugs that are harmful when combined with other drugs
  • Drugs that you should use only for certain health conditions
  • Drugs that are often misused or abused
  • Drugs that a doctor prescribes when less expensive drugs might work better

How do I find out if my medication needs prior authorization?

We cover certain drugs under the pharmacy part of your insurance and others under the medical part of your insurance.

What should I do if my prescription needs prior authorization?

If your drug needs approval, either you or your pharmacist will need to let your doctor know. Your doctor might switch you to another drug that doesn’t need prior approval. Or, they can contact our Pharmacy Help Desk to start the approval process and tell us the information we need.

If the drug is on the medical part of your benefit, talk to your doctor about getting preapproval for it.

If you have an HMO plan with Blue Care Network, you can fill out our callback form. Once you submit the form, someone will contact you to help you request prior authorization for a medication. 

If you have a PPO plan and need your request taken care of right away, fill out our expedited request form.