Prior authorization is a kind of approval that’s necessary for certain procedures, hospital admissions or prescription drugs.
- For in-network care, the primary care physician or specialist is usually responsible for prior authorization.
- For out-of-network care, the member is responsible for prior authorization.
- For most prescription drugs, your provider can submit a prior authorization form.
Certain procedures and services require review and approval before they can be provided. These vary depending on your plan, so it’s best to check before scheduling anything.
The following list includes procedures and services that typically require prior authorization:
- Artificial Insemination
- Habilitative Services
- Inpatient Services
- Inpatient Hospital Care
- Inpatient Rehabilitation
- Maternity Services for Extended Stays
- Skilled Nursing Facility Admissions
- Intensity Modulated Radiation Therapy (IMRT)
- In Vitro Fertilization
- Outpatient Hospital Services
- All Outpatient Hospital Services
- Pre-implantation Genetic Testing
- Proton Beam Therapy
- Sleep Studies (Attended)
- Specialty Medications
- Stereotactic Radiosurgery
This list is by no means exhaustive and is subject to change. In general, prior authorization is required for complex services or new specialty drugs. It’s one of the ways we try to keep costs down and ensure you’re getting exactly the care you need.
If you’re considering treatment that falls outside of your normal medical routine, be sure to call the Member Services number on the back of your member ID card to see if you need prior authorization.
There are two ways to tell if your drug needs prior authorization:
- Search the formulary
- Call CareFirst Pharmacy Services at 800-241-3371
Drugs that require a prior authorization are subject to change and are subject to your benefit plan.
NOTE: Your employer may have excluded some drugs from your plan.
No. Once a prior authorization is given, it is typically valid for four (4) months to one (1) year.
Have your pharmacist call your doctor to start the prior authorization process. The request will be approved or denied within 48 hours after the provider provides all the requested information.
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The following questions are best answered by one of our Member Services experts.
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Support & Service
Need help with your plan?
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Member Services
If you have additional questions, call Member Services using the phone number on the back of your ID card
Having technical problems?
Can’t log in? Page not loading? Things not working the way they should? We can help.
Technical Help
Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET
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The following questions are best answered by one of our Member Services experts.
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Support & Service
Need help with your plan?
Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.
Member Services
If you have additional questions, call Member Services using the phone number on the back of your ID card
Having technical problems?
Can’t log in? Page not loading? Things not working the way they should? We can help.
Technical Help
Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET
Questions that Require Phone Support
The following questions are best answered by one of our Member Services experts.
- I can’t find a medical specialist for a specific issue. Can you help me?
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Support & Service
Need help with your plan?
Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.
Member Services
If you have additional questions, call Member Services using the phone number on the back of your ID card
Having technical problems?
Can’t log in? Page not loading? Things not working the way they should? We can help.
Technical Help
Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET
Questions that Require Phone Support
The following questions are best answered by one of our Member Services experts.
- How can my healthcare plan help me save money?
- Am I eligible for any non-medical discounts through CareFirst?
Support & Service
Need help with your plan?
Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.
Member Services
If you have additional questions, call Member Services using the phone number on the back of your ID card
Having technical problems?
Can’t log in? Page not loading? Things not working the way they should? We can help.
Technical Help
Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET
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