Prior Authorization: What You Need to Know

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.

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

  • 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

  • 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.