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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:

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.

Questions that Require Phone Support

The following questions are best answered by one of our Member Services experts.

  • How do I get immediate help with a change in my membership?
  • When will I get my new member ID cards?
  • How do I get proof of coverage or a letter of credible coverage?
  • How do I get help if I’m having technical issues with the website?

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.

  • Can you help me understand how my insurance plan works?
  • How do I get assistance with complex benefits or specific benefit issues?
  • How do I get more information about a particular treatment/service I’m considering?
  • How do I find out if I need prior authorization for a procedure?
  • What’s the status of my prior authorization request?
  • How do I know how many visits I have remaining for a specific service (e.g., physical therapy)?
  • How do I know how much money I have remaining in my allowance for a specific service (e.g., infertility treatments)?

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.

  • What’s the status of my claim appeal?
  • Can you explain the denial code on my benefits claim?
  • Can you help me with a claim I think has been processed incorrectly?
  • Why is my claim being adjusted?
  • Why was my claim with my in-network doctor processed as out-of-network ?
  • Can you help me figure out how much I owe and to whom?
  • Can you help me update my Coordination of Benefits (COB)?
  • Can you help me with a routine visit that requires applied a cost share/patient liability?
  • What’s the status of my over-accumulation review?

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?
  • I can’t find a mental health specialist for a specific issue. Can you help me?
  • Can you help me find an in-network doctor who doesn’t appear when using the Find a Doctor tool?
  • Do I need prior authorization for a procedure I’m considering?
  • Do I need a referral to see a specialist?
  • Can you tell me if a doctor who’s not listed as a pediatrician works with children?

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

Related Resources for "Plans & Coverage"

Wellness Programs Overview

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Prescription Drug Forms

Find forms for prescription drug-related requests, exceptions and orders here.