Blue cross blue shield medication prior authorization

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Table of Contents Show

What is electronic prior authorization (ePA)?
Why use ePA?
How can prescribers transmit ePA requests?
Why do insurance companies require prior authorization for prescriptions?
What does prior authorization mean for prescriptions?
How long does prior authorization take for Adderall?
What services does not require prior authorization?

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ការជូនដំណឹង៖ ប្រសិនប. ើអ្នកនិយាយភាសា ខ្មែរ សេ វាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសម្ រាប ់អ្នក។ សូមទូរស័ព្ទទ ៅផ ្នែ កសេ វាសមា ជិកតាមល េខន ៅល. ើប ័ណ្ណ សម្ គាល ់ខ្លួ ខ្លួ នរប ស់អ្នក ហៅ 1-800-472-2689 (TTY: 711) ។

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Providers can submit prescription drug prior authorization (PA) requests electronically for Blue Cross and Blue Shield of Minnesota members who have Prime Therapeutics as their pharmacy benefit manager (PBM) and for specialty drugs covered under the medical benefit.

What is electronic prior authorization (ePA)?

ePA is the process a prescriber (e.g., doctor) follows to transmit a pre-certification or pre-authorization coverage request to a payer (e.g., health plan, pharmacy benefit manager) to check benefit coverage for a specific drug and patient. Pre-authorization is based on medical necessity review and is not a guarantee of payment. Payment requires that the patient's benefit contract is in force on the day services are provided by the prescriber and is subject to all provisions and limitations in the subscriber's contract including any applicable contract exclusions, health plan allowed amounts, prior treatment, medical necessity policies, and clinical diagnosis/findings.

Historically, providers have used facsimile (fax), mail, and telephone to send PA drug requests and clinical information to payers. However in recent years, providers have started submitting online PA drug requests using payer-specific web portals or Electronic Medical Record (EMR) systems that can transmit a secure electronic file that follows the National Council of Prescription Drug Programs (NCPDP) standard file format.

Why use ePA?

Submitting prescription drug PA requests electronically via payer-web portals and EMR systems offers many time-saving features to prescribers and payers.
ePA tools can help identify for prescribers what clinical information is needed for a payer to complete a medical necessity review.
In Minnesota, state law requires prescribers exchange drug PA requests electronically to support the industry movement toward electronic PA processing and away from paper and fax-based workflows.

How can prescribers transmit ePA requests?

Prescribers can submit ePA drug requests for Blue Cross members who have pharmacy benefits through Blue Cross by either submitting a request through CoverMyMeds's free web portal or by sending an electronic NCPDP file to Prime through an integrated Electronic Medical Record (EMR) system during the e-prescribing process.

For specialty drugs covered under a Blue Cross member's medical benefits, prescribers can submit ePA requests online thru Availity or transmit NCPDP file requests to Blue Cross from their EMR system via CenterX. To learn more about how to transmit NCPDP files, prescribers can talk with their EMR vendor and/or contact CenterX at 855-CenterX (236-8379) or .

Learn more

NCPDP ePA Fact Sheet (PDF)
CoverMyMeds ePA

Why do insurance companies require prior authorization for prescriptions?

Your insurance company may require prior authorization before covering certain prescriptions. This is to ensure that the medication is appropriate for your treatment. It also helps to make sure it's the most cost-effective option. When prior authorization is granted, it is typically for a specific length of time.

What does prior authorization mean for prescriptions?

What is prior authorization? This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. If you don't get prior authorization, a medication may cost you more, or we may not cover it.

How long does prior authorization take for Adderall?

Please allow additional time for this process: approximately two business days for standard prior authorization and approximately one business day for an urgent prior authorization request.

What services does not require prior authorization?

No pre-authorization is required for outpatient emergency services as well as Post-stabilization Care Services (services that the treating physician views as medically necessary after the emergency medical condition has been stabilized to maintain the patient's stabilized condition) provided in any Emergency Department ...