Prior Authorization Changes for Some Commercial and Government Program Members

March 31, 2026

We’re changing prior authorization requirements that may apply to some commercial, Medicaid and Medicare Advantage members.

Changes are based on updates from utilization management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System code changes from the Centers for Medicare & Medicaid Services.

For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Texas. Utilization management and related services for Medicare Advantage members will be reviewed by BCBSTX and EviCore healthcare. Carelon Medical Benefits Management and Alacura Medical Transportation Management will review utilization management and related services for some commercial members.

These changes for commercial members begin April 1, 2026:

Replacement of medical oncology codes reviewed by Carelon

These changes for commercial members begin April 1, 2026:

Addition of radiation oncology codes to be reviewed by Carelon
Addition of advanced imaging codes to be reviewed by Carelon
Addition of sleep codes to be reviewed by Carelon
Addition of molecular genetic lab codes to be reviewed by Carelon
Addition of medical oncology codes to be reviewed by Carelon
Addition of drug codes to be reviewed by BCBSTX

These changes for Medicare Advantage begin July 1, 2026:

Implementation of Part B Step Therapy Program for BCBSTX

These changes for Medicare Advantage begin July 1, 2026:

Addition of orthotic codes to be reviewed by BCBSTX
Addition of new MAPD codes to be reviewed by BCBSTX
Addition of pharmacy codes to be reviewed by BCBSTX
Addition of miscellaneous codes to be reviewed by BCBSTX

These changes for members of Medicaid begin May 31, 2026:

Removal of drug codes previously reviewed by BCBSTX

These changes for members of Medicaid begin June 1, 2026:

Addition of drug and durable medical equipment codes to be reviewed by BCBSTX

For more information, refer to prior authorization lists in utilization management.

Always check eligibility and benefits first through Availity® Essentials or your preferred vendor prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.

Checking eligibility and/or benefit information and/or obtaining prior authorization 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 coverage contract or guide. If you have any questions, call the number on the member's ID card.

Services performed without required prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. EviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSTX. Carelon Medical Benefits Management is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX. Alacura Medical Transportation Management, LLC. is an independent company that has contracted with BCBSTX to provide utilization management services for participants with coverage through BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.