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Many times, your doctor will need to get approval — prior authorization — before your plan will cover certain health care services and medicines. Your doctor may also call it preauthorization or preapproval. Worried that getting prior authorization might be a hassle? It’s easier than you think. Here’s what you need to know.
Why is prior authorization important?Some health care services and prescription drugs must be approved by Blue Cross and Blue Shield of Illinois before they are covered under your plan. This is how we support you in getting the right care, at the right place and at the right time.
How does prior authorization work?Your doctor will submit a prior authorization request before ordering a test or medication. If the request for prior authorization isn't approved, your insurer will let you and your doctor know. If that happens, you and your doctor may choose another treatment option or offer more information so the request can be reviewed again.
If your providers aren't in network, you'll be responsible for getting the prior authorization. If you don't, your health plan may not cover the cost.
Which health care services need prior authorization? Things like diagnostic images and complex care need prior authorization before you are treated. Prior authorization for MRIs and CT scans is standard. Your care provider will know to ask first, but don’t be afraid to make sure. Each plan is different, so it's always good to ask.
Log in to your Blue Access for MembersSM (BAMSM) account on your computer or with the BCBSIL mobile app. Then you can set your notification preferences to get status updates on your prior authorizations via email or text.
What prescription drugs call for prior authorization?Drugs that may be unsafe when used with other medications need prior authorization. Some drugs that are FDA-approved for one health condition but are being prescribed for a different health issue may need review. Drugs that are often misused may also be on the prior authorization list. If you have coverage with BCBSIL’s pharmacy benefit manager Prime Therapeutics*, you can find out which drugs need prior authorization. Go to MyPrime.com and look under Medicines. You can also call the customer service number on your member ID card.
Medications that need approval will only be covered by your plan if your doctor gets prior authorization.
What should I do if a drug or service needs prior authorization?If you are seeing an in-network doctor, your doctor will need to submit a request. You may also want to call the customer service number on your member ID card to make sure your doctor asked for prior authorization.
If you are going to a doctor who is not in your plan's network, contact us to get prior authorization. Call the customer service number on your member ID card to determine the next steps.
What happens if my prior authorization isn’t approved? If coverage for a health care service or medication is denied, you and your doctor may change your treatment plans. If you get the service or drug without prior authorization, you will have to pay the costs. You have the right to appeal the decision. Information about the appeal process is included with the decision notification. You can also find it in your benefits documents.
Originally published 5/13/2015; Reviewed 2022; Revised 2021, 2023, 2024
Colin - you can call the number on the back of your member id card, or send us a private msg & we will review your plan & help determine if this surgery center is in network. - HeatherA
My wife, who is on my Healthcare plan is having Knee surgery. I want to be certain that the Surgery Center she is having the surgery at is an In-Network center. How do I confirm this?
To check your benefit information, Log in to your Blue Access for MembersSM (BAM)SM account. Select the My Coverage tab and click on the prior authorization link under My Coverage Benefits. Next, click Referral and Prior Authorization Information. Or call the number on the back of your member id card. - HeatherA
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