Some prescription medications require prior authorization before they can be filled. This means your health insurance provider reviews the medication before it’s covered to make sure it is:
- Clinically appropriate
- Used safely and effectively
- Covered under your health plan
In some cases, these medications must also be filled at an in‑network specialty pharmacy (this is uncommon).
Certain prescriptions need extra review because they may require:
- Special education to help you use the medication or device safely
- Close monitoring to make sure the medication is working as intended
- Patient‑specific dosing or adjustments
- Special handling, storage or delivery (such as refrigeration or home delivery)
This review is completed by doctors, nurses, and other clinically qualified experts.
Prior authorization may be required for medications such as:
- Medications not covered by your specific plan
- Birth control exceptions
- Doses that exceed your plan’s quantity limits
- Step therapy medications (trying one medication before another)
- Fertility medications
- Hepatitis C medications
Prior authorization requirements vary by plan. Your doctor or pharmacist can help determine whether approval is needed.
Your provider submits the request
Your provider sends information to your health plan explaining why the medication is needed.
Clinical experts review it
The request is reviewed to ensure the medication is appropriate and covered.
You’re notified of the decision
Once a decision is made, you and your provider are informed. Typically, you will receive a letter in the mail if it’s been approved or denied with additional information and instructions.
What you can do now
- Talk with your doctor or pharmacist. They can explain why a medication needs approval and discuss alternatives if needed.
- Use in‑network pharmacies. Some medications must be filled through a specialty pharmacy in your network.
- Check the status or ask questions. Start with the pharmacy customer service number on the back of your member ID card.
Need help or have questions?
If you have questions about:
- Prior authorization requirements
- In‑network or specialty pharmacies
- Coverage for a specific medication
- A denied prior authorization
Call the pharmacy customer service number on the back of your member ID card or sign in to Blueprint Portal and access the Pharmacy Center. We’re here to help you understand your options and next steps.