2020 New Prior Authorization Requirements and Introduction of MyBlue HealthSM

Sept. 25, 2019

There are important changes coming to the prior authorization requirements for members with, Blue Choice PPOSM, Blue EssentialsSM, Blue Advantage HMOSM and Blue PremierSM. In addition, we are implementing our new focused network, MyBlue Health, effective Jan. 1, 2020. The prior authorization requirements for MyBlue Health will be the same as our Blue Advantage HMO plan.

Beginning Jan. 1, 2020, prior authorization will be added or expanded on the above benefit plans for the following services:

  • Outpatient provider administered drug therapies, including Cellular Immunotherapy, Gene Therapy and other medical benefit drug therapies.

Providers can locate a list of the procedure codes being added for these drug therapies by reviewing the “Specialty Drugs Prior Authorization List” located on the provider website under Clinical Resources/Prior Authorization & Predeterminations then select Prior Authorization Requirements for Commercial and Retail Plans.

It is critical that providers use Availity® or your preferred vendor to check eligibility and benefits, determine if you are in-network for your patient and whether any prior authorization or prenotification is required. Availity allows you to determine if prior authorization is required based on the procedure code. Refer to “Eligibility and Benefits” on the provider website for more information on Availity.

Payment may be denied if you perform procedures without authorization. If this happens, you may not bill your patients.

To prior authorize services through BCBSTX, use iExchange® or call the phone number listed on the member’s ID card. For more information or to set up an iExchange account, refer to iExchange on the provider website.

If you need assistance, view the list of our Network Management offices to contact.


As a reminder, it is important to check eligibility and benefits before rendering services. This step will help you determine if benefit prior authorization is required for a member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSTX’s provider website.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.

iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, Aerial or Medecision. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.