Prior Authorization – BCBS
Who is responsible for getting a prior authorization from Blue Cross and Blue Shield of Florida?
• If your doctor is a Blue Cross and Blue Shield of Florida participating network provider, he or she is responsible for obtaining a prior authorization and should contact us for you.
• If your doctor is NOT a Blue Cross and Blue Shield of Florida participating provider or is located outside of Florida, it’s your responsibility to ensure that your doctor gets a prior authorization for you. It’s easy to initiate: Simply have your non-network or out-of-Florida doctor call the number on the back of your ID card. If a prior authorization is not obtained, you may be responsible for the entire cost.
Important note: In an emergency situation, a prior authorization is NOT required. An emergency is an instance in which the absence of medical attention could jeopardize a person’s life, health, or ability to regain maximum function, or could subject a person to severe pain.
What types of medical services require a prior authorization?
Certain medical services, medical supplies and prescription drugs that may require a prior authorization are listed below. Please refer to your benefit booklet and pharmacy endorsement (if applicable) for prior authorizations that may be required by your medical and/or prescription drug coverage.
Examples that may require a prior authorization:
• Hospital Admissions
• Diagnostic imaging such as CT scans, MRIs/MRAs, PET scans and nuclear medicine
• Behavior/Mental Health Services
• Durable Medical Equipment and supplies, such as crutches, hospital beds and wheelchairs and orthotic/prosthetic equipment.
• Specialty drugs such as high-cost oral, injectable and infused medications that are used to treat and manage complex diseases such as multiple sclerosis, cancer, hepatitis C and certain forms of rheumatoid arthritis
• Drugs administered in the physician/provider’s office
• Certain brand-name drugs that have generic equivalents may not be covered or may be covered at a higher cost, unless the generic equivalent is tried first (this depends on your benefits)
