My Coverage Explained

Prior Authorization: What You Need to Know

In some cases your doctor may need to get approval from us before your plan will cover certain health care services and medicines. This need is called prior authorization. Think this is a pain? It’s actually much easier than you think.

To help you get a better idea of how prior authorization works we have answered some of the most popular questions from members.

What is prior authorization?
Certain health care services and prescription drugs will need to be approved by Blue Cross and Blue Shield of Illinois (BCBSIL) before they are covered under your plan . This is called prior authorization. It can also be called preauthorization, pre-certification or preapproval.

Which health care services require prior authorization?
You can find out if a health care service needs pre-approval from BCBSIL by calling Customer Service at the number on the back of your member ID card.

What prescription drugs call for prior authorization?
You can find examples of drug categories and specific meds that may need preapproval on Prime Therapeutics’ website* under the “Find Medicine” tab. You can also get information on a specific medication by calling the Pharmacy Program phone number on the back of your BCBSIL member ID card.

What should I do if I find out that a drug or service needs prior authorization?
If you are seeing an in-network doctor, your doctor will need to submit a request for prior authorization. You may also want to call the Customer Service number on your BCBSIL member ID card to make sure the prior authorization request was put in place.

If you are going to a doctor that is not in your plan’s network , you will have to contact us to get prior authorization. You can start the process by calling the Customer Service number on your BCBSIL member ID card.

What happens if I don’t get approval?
If coverage for the health care service or prescription drug is denied, you will be responsible for the cost of that service or drug. You certainly have the right to appeal the decision . You can find information about the appeals process in your benefits documents.

Still have questions? Ask away! Post them below or call the Customer Service number on your BCBSIL member ID card.

* Depending on your coverage, your prescription drug benefits may not be administered by Prime Therapeutics. If that’s the case call the Pharmacy Program number on the back of your member ID card to see if your medicine needs preapproval.

Comment

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  • Will a doctor's request for prior authorization show up under the claims section in blue access members website?

  • Hi Roon10- Good question! No, it will not show up on your Blue Access account. If you have questions regarding a prior authorization, you're able to contact us or your provider for an update. --Tonya

  • where do I find the form to complete to get a preauthorization for a procedure

  • Hello Amy.  Most In Network providers will submit the preauthorization on your behalf.  I would recommend talking to your doctor to see if they have submitted any documentation.  If you do have to submit your own documentation, I would recommend contacting Customer Service.  Documentation required can vary depending on the service and there is not a specific form for preauthorization of a service. - Renee

  • I have been talking Eloquis for blood clots in my lungs and legs since August.  As of January 1 my medication is not covered forcing me to use Xarelto which has been advertised on TV as have very bad side effects.  Can I PLEASE  get approval for my Eloquis prescription!

  • I have contacted the numbers on the back of my membership card and still cannot get a direct answer to why my prescription for Eloquis which I have to take for blood clots in my legs and lungs will not be approved . Instead I'm being forced to switch to Xarelto which had class action lawsuits pending very bad adverse effects. WHY can't I get approval for continued use of Eloquis?  

  • Hi William, If you'd like to send us a private message I can have my team take a look at what's going on with your medication. ~ Kayla

  • How can I check the status of my pre-authorization?  Every time I call, I get put on hold or get different information on the status.  Is there a way to look at my chart myself?

  • Is there a direct number to talk to someone about my pre-authorization?  All the numbers lead me to the "provider" line.  Very frustrating, especially when I am on a timeline for my surgery.  

  • Hi Kristi, Are you calling from a doctors office or hospital? If so, your call will automatically be directed to the provider services area. I recommend contacting customer service from a different phone number as they'll be able to connect you with the pre-authorization department. There is not a way for you to view this information yourself.

    If you just have questions of whether or not your pre-authorization was approved you can send us a private message and my team can check on this for you. ~ Kayla

  • How do I send a private message?  Thank you!

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