Prior Authorization

Some services for health care and certain drugs require approval from Blue Cross and Blue Shield of Texas. This approval is called “prior authorization” (“PA”). If BCBSTX does not approve the services or drugs, the costs will not be covered (paid) by BCBSTX.

How It Works

Work with your provider. They know what needs to be approved and can make the PA request. If the treatment or drug you need requires approval, your provider will need to get this from BCBSTX to make sure the service is covered. Both BCBSTX and your PCP (or specialist) will agree ahead of time what treatments you need are medically necessary. “Medically necessary” refers to getting care that:

• Protects life
• Keeps you from getting seriously ill or disabled
• Finds out what’s wrong or treats a disease, illness or injury
• Helps you do things like eating, dressing and bathing

Your PCP may send you to a different provider for special care or treatment. A specialist may treat you for as long as they think you need it. BCBSTX allows members with special health care needs to have direct access to the right specialists. This includes a standing referral to a specialty doctor or having a specialist as a PCP if needed. Check with your PCP to make sure you don’t need to get approval for this care.

Some services that do not need approval are:

• Family planning
• OB/GYN services (you must choose providers in your health plan’s network)
• Emergency care
• Well-Child Check-ups for CHIP members
• Texas Health Steps medical checkups for STAR and STAR Kids members
• Early Childhood Intervention (ECI)
• Sexually Transmitted Infections (STI)/HIV
• Case Management for women and children

Some behavioral health and substance use treatments may need approval. Others may not. For example, outpatient therapy and psychological testing do not need approval. Your provider will know and can request approvals when needed. Check the Member Handbook for your plan to find out what treatments need PA.

Some prescription drugs will need approval. For example, if your doctor prescribes the drugs below, they will need to be approved before they can be covered.

• Growth hormones
• Dupixent
• GLP-1 drugs for diabetes
• ADHD meds
• Treatment for cystic fibrosis

Search the VDP Drug List to learn if approval is needed for a drug. You can also ask your doctor what drugs require approval.

In-Network and Out-of-Network

You should go to providers or pharmacies that are in network. They will know what needs approval. If you want to go to out of network, work with your Service Coordinator or call the Customer Advocate Department to learn about your options.

Call the Customer Advocate Department if you have questions about health care or drugs that need PA or if you need help making an appointment with a specialist.

Need to locate a provider or a pharmacy? Search the Provider Finder for your plan:

• CHIP Provider Finder^®
• STAR Provider Finder
• STAR Kids Provider Finder

How Does BCBSTX Approve a Request?

Our doctors and staff make decisions about your care based on need and benefits. They will also use tools such as medical codes, policies and clinical criteria to prescribe the most appropriate treatment. Your provider will order any medically necessary services. BCBSTX will only pay for medically necessary covered services.

Ask your provider to confirm what needs to be approved before you get a specific drug, medical device or treatment. Your provider should check the Prior Authorization Requests page for information on services that may need approval. There they also can access forms to make a PA request.

Prior Authorization Statistics

Check out the PA Data Report. This report provides results from last year for PA requests for Medicaid members. It includes data for medical and behavioral health care.

The report shows:

• How many requests were approved or denied
• How quickly decisions were made
• Average and middle (median) wait times
• Whether a request was urgent
• Approvals made after appeals or deadline extensions