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Prior Authorization

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What Is Prior Authorization?

Sometimes, you may need to get approval from Blue Cross and Blue Shield of Texas before we cover certain health care services and prescription drugs. 

This is called prior authorization, sometimes called prior authorization, preauthorization, pre-certification or prior approval. 

When prior authorization is needed, we, along with outside vendors1, review the requested service or drug to find out if it’s medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

Resources

Do You Need Prior Authorization?

If you're fully insured2, look up procedures, prescription medicines and behavioral health service that might require prior authorization.

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Medical Procedures

Medical procedures like some surgeries, transplants, imaging and other tests often require prior authorization.

Search medical procedures

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Medical or Prescription Drugs

Search medical drugs, like your prescriptions or specialty prescriptions, that may require prior authorization.

Search medical drugs

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Behavioral Health Services

Prior authorization may be required for some behavioral services like psychological testing or psychiatric care.

Search behavioral health care

Review BCBSTX's Prior Authorization Code Lists

To find the full list of services and drugs that require prior authorization, click below to download a copy of the spreadsheet. Except as otherwise noted, these prior authorization requirements are effective as of Jan. 1, 2025:

 

History

How BCBSTX Responds to Prior Authorization Requests

We keep track of how many prior authorization requests we receive, approve and deny each year. To review the statistics of prior authorization health data, click on the buttons below to search. For best results, use Google Chrome.

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Medical History

Medical health history includes history data for surgeries, transplants, etc.

Review medical data

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Medical Drug History

Medical drugs history includes history data for medicines or prescriptions.

Review drugs data

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Behavioral Health History

Behavioral health history includes data for mental health, psychiatry, etc.

Review behavioral data

Review BCBSTX's Prior Authorization Data

To find the full list of history for all prior authorization data, click below to download a copy. You can review data for the last 4 years or longer.

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Requesting Prior Authorization

We Make Requesting Simple

Most of the time, your doctor will take care of prior authorization before offering care. But, it’s always a good idea to check, especially if your doctor's not in network. If you use an out-of-network doctor, you may need to handle prior authorization. Start by calling the number on your member ID card.  

When you call, we'll need the following information:

  • Your name, subscriber ID number and date of birth
  • Your provider’s name, address and National Provider Identifier (NPI)
  • Information about your medical or behavioral health condition
  • Your provider's proposed treatment plan, including any diagnostic or procedure codes
  • When you'll get care and, if you're being admitted, an estimated length of stay
  • Where you’re being treated

Search In-Network Care

Not Sure If Your Doctor's In Your Network?

Log in to your member account and use our Provider Finder® tool to search for in-network doctors, hospitals and providers.

Log In to Search
 

Resources

Helpful Articles for Prior Authorization

1Carelon Medical Benefits Management (Carelon) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSTX.

eviCore® is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Texas.

2Not sure if you’re fully insured? Check with your HR department or benefits administrator. If you aren’t fully insured, check your benefit booklet to learn your list of services that require prior authorization. If you still have questions, please call the Customer Service number listed on your BCBSTX member ID card.