Medical and Part B Medication Prior Authorization

Prior authorization means that your doctor must get approval from Blue Shield before administering specific medications or performing a particular medical service or operation. Without this prior approval, Blue Shield may not pay for your medication or medical care, and you will have to pay out of pocket.

Medical care

Access the criteria used to make decisions about the medical care you receive.

View guidelines

Part B medications

Part B medications are drugs you get at a doctor's office or in a hospital outpatient setting.

About Part B Step Therapy
If you are enrolled in a Blue Shield Select (PPO) or Blue Shield Medicare (PPO) plan, your Part B drugs may be subject to step therapy.

View the Part B Step Therapy criteria:

About Part B Medication Authorization

If you are enrolled in a Blue Shield Select (PPO), Blue Shield Medicare (PPO) plan, Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield Inspire (HMO D-SNP), Blue Shield Inspire (HMO), and  Blue Shield TotalDual Plan (HMO D-SNP) your Part B drugs may be subject to prior authorization.

View the Part B Medication criteria:

  • English (PDF, X KB)

Part B Inflation Rebate Program

The list of Medicare Part B rebatable drugs and adjusted coinsurance amounts for these drugs are published quarterly by the Centers for Medicare and Medicaid Services (CMS). 

View the current Part B rebatable drug coinsurance rates:

Remember, it’s always important to check that the service or drug you need is a covered benefit under your plan. For any questions about prior authorization, please call Customer Service at the number on the back of your Blue Shield member ID card.

 

Page last updated: 10/18/2024

*Free digital copy with no obligation to enroll.

† Blue Shield Medicare Advisers are available April 1 through September 30: 8 a.m. to 8 p.m., weekdays and October 1 through March 31: 8 a.m. to 8 p.m., seven days a week.

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California Physician’s Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

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For Blue Shield Medicare Advantage Plans: Blue Shield of California is an HMO, HMO D-SNP, PPO and a PDP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.

 
 
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