Blue Cross and Blue Shield of New Mexico

In some cases, your doctor may need to get approval from your insurer 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 frequently asked questions from members.

What is prior authorization?
“Prior authorization” refers to certain health care services and prescription drugs that will need to be approved by your insurer before they are covered under your plan. You may also hear it called “preauthorization”, “pre-certification” or “preapproval”.

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. 

If you are going to a doctor that is not in your plan’s network , you will personally have to directly contact your insurer to get prior authorization. 

What prescription drugs call for prior authorization?
You can find examples of drug categories and specific meds that may need preapproval through your insurer. 

Which health care services require prior authorization?
You can find out if a health care service needs pre-approval from your insurer.

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 full cost of that service or drug. You of course have the right to appeal any decisions made regarding prior authorization. Details about the appeals process can be found in your benefits documents.

Still have questions? No problem! Post them below!