Prior Authorization: What You Need to Know

Understanding your health insurance is the best way to enjoy all its benefits. When you know what steps you need to take before treatment, things go more smoothly. One of the most important steps is prior authorization.

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 and preapproval. Worried getting prior authorization might be a hassle? Don’t fret. 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 New Mexico (BCBSNM) 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 info 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, we 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.

Downloading the Mobile app to connect to your Blue Access for Members^SM account allows you the option to select your notification preferences to receive immediate status updates via email or text on your prior authorizations.

What prescription drugs call for prior authorization?
Drugs that may be unsafe when used with other medications need prior authorization. Also, drugs that should only be used for certain health conditions are on the prior authorization list. So are abused and misused drugs. If you have coverage with BCBSNM’s pharmacy benefits manager, Prime Therapeutics*, you can find examples that may need prior authorization. Go to myPrime.com  and look under the “Find Medicine” tab. You can also call the Pharmacy Program number listed 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 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 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. Find information about the appeal process in your benefits documents.

Still have questions? Ask away! Post them below or call Customer Service to talk with a customer advocate.

* Depending on your plan, your prescription drug benefits may not be handled by Prime Therapeutics. If not, call the Pharmacy Program number on the back of your member ID card to see if your medicine needs prior authorization.

Prior Authorization review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations and exclusions of this Certificate. The notification timeframes for calling Blue Cross and Blue Shield and benefit reductions are described below under the provision entitled Benefit Reductions for Failure to Obtain Prior Authorization or Notify. You are responsible for making sure your prior authorization requirements are met.

Originally published 8/21/2015; Revised 2021