Prior Authorization & Clinical Guidelines

Our goal is to work closely with providers to streamline and expedite prior authorization requests for our members.

Referrals
A referral is a written order from your primary care provider (PCP). In some situations, our plan or your PCP must give you a referral for you to get certain medical services from another provider in our plan.

You can get the services listed below without getting a referral from your PCP.
- Emergency care or urgently needed services
- Flu shots, COVID-19 vaccinations, Hepatitis B vaccinations, and pneumonia vaccinations
- Routine women’s health care includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams as long as you get them from an in-network provider.
- In-network Specialist provider office visits do not require a referral, except for pain management services.
You can also get other kinds of care without a referral from your PCP (see Section 2.2 of Chapter 3 in your Evidence of Coverage).
Prior Authorizations
Some medical tests or services require prior authorization before they are scheduled. Your provider requests prior authorization on your behalf. A prior authorization, commonly called a ‘PA’, is not a promise we will cover the cost of the service.

A PA request is a form your provider fills out and sends it to us. Our prior authorization department will review the request and make a decision. A decision for a standard request is made within 14 calendar days and a decision for an expedited request is made within 3 calendar days. You and your provider will be notified if the service is approved or denied.

If you have a question about referrals and prior authorizations, Member Services can help you. Call us at 1-800-656-8991 (TTY 711). Our Member Services department is open 8 a.m. to 8 p.m., 7 days a week. You can also contact us by e-mail at HCHComments@azblue.com.

You can review our Prior Authorization metrics report here.

Prior Authorization Guidelines

- Medical PA Phone: 1-800-656-8991, TTY: 711, 8 a.m. to 8 p.m., 7 days a week
- Medical PA Fax Line: 1-877-424-5680
- Pharmacy PA Fax Line: 1-877-424-5690
- Prior Authorization Grid effective 1/12/2026
- Prior Authorization Grid effective 7/1/2025
- Prior Authorization Grid effective 4/10/2025
- Prior Authorization Grid effective 3/1/2025
  
  Clinical Guidelines and Recommendations
  
  Centers for Medicare and Medicaid Services – Medicare Coverage Database
  
  Our plan utilizes:
  
  National Coverage Determinations (NCD)
  
  Local Coverage Determinations (LCD)
  
  InterQual
  
  UpToDate
  
  Oncology Clinical Practice Guidelines
  
  DrugDex AHFS (subscription required)
  
  Arizona Controlled Substance Prescription Drug Monitoring Program (login required)

Clinical Guidelines

Centers for Disease Control and Prevention (CDC)
- Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children – PMC
American Psychiatric Association
- Practice Guideline for the Treatment of Patients with Major Depressive Disorder
- Major depressive disorder: Validated treatments and future challenges - PMC (nih.gov)
American Academy of Neurology (AAN)
- Practice Guideline Update: Acute Treatment of Migraine in Children and Adolescents
- Practice Guideline Update: Pharmacologic Treatment for Pediatric Migraine Prevention
American Academy of Pediatric Dentistry (AAPD)
- Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents