Prior Authorizations

What to Know about Prior Authorizations and Referrals

You may hear these words used by us or your provider, prescriber, or pharmacist. Prior authorization is a way for health plans to make sure their members get medically necessary care. It's also a way to help ensure your safety, control costs, and keep health care affordable.

What is prior authorization?

Simply put, it's getting approval for a medical service or drug from your health plan in advance of receiving the care or drug.

How does prior authorization work?

If your provider or prescriber thinks you need a certain type of care or drug, and that care or drug requires prior authorization, she or he will need to take steps to get approval.

1. They will contact us with the prior authorization request (by phone, email, or fax).
2. They will need to submit medical records with the request that say why you need the care or drug.
3. After we have all the information, we will review it. If more information is needed to make a decision, we'll work your provider or prescriber to get it.
4. We're required to make a decision within a certain amount of time. NOTE: Medicare has requirements about how much time we can take to make a decision. Check out our Evidence of Coverage (EOC) documents for these time periods.
5. We will let you and your provider or prescriber know our decision within the required time period. We'll send you a letter with our decision.
6. If we do not approve the prior authorization request, you can ask us to review it again. This is called making an appeal. You must ask us for an appeal within 60 days of the date on the letter with our denial.

What else do I need to know?

• Your provider or prescriber will ask for a prior authorization for you. They will be able to provide all the needed information.
• If your health requires you to get care or a drug quickly, your provider or prescriber can ask us to make a fast decision. Fast decisions have different time period requirements for us to make a decision.
• Not all care or drugs require prior authorization.
  • Our EOCs (Chapter 4) will tell you which services require it.
  • Our Formulary (or Drug List) will tell you the drugs that require it.
• IMPORTANT: If you get care or a drug without prior authorization when it's required, we may not pay for that care or drug. You may have to pay the full cost.
• If you're a member on one of our private fee-for-service (PFFS) plans, you do not need prior authorization for covered services. If the PFFS plan offers drug coverage, prior authorization may be required for certain drugs.

What's a referral?

A referral is different than prior authorization. A referral is a written order from your PCP for you to see a specialist or get certain medical care. None of the services we cover require you to get a referral from your PCP.

Want to learn how our prior authorization process worked in 2025?

Click the link below to see how many prior authorization requests we received, how many were approved or not approved, and other helpful information.

View Prior Authorization Metrics