Prior Authorization and Medical Policies
Prior authorization is the review process Blue Cross Blue Shield of Arizona (AZ Blue) uses to determine your eligibility for a particular procedure or medication before you receive it.
- We base our authorization decisions on your eligibility, health condition, specific benefits in your plan, and any clinical guidelines we use to determine if the care is medically necessary for your situation.
- Regardless of prior authorization decisions made by AZ Blue, patient care decisions are made between the provider and patient.
Note: The fact that a provider has prescribed, ordered, recommended, or approved a service for you does not make it medically necessary or make the service eligible for your health plan benefits, even though it may not be expressly excluded in your benefit book.
Prior authorization requirements may be different, depending on who is taking care of prior authorization for your plan. Your provider can check requirements for a particular service or medication. If prior authorization is required, your provider will request it from AZ Blue, according to the information on your ID card.
Here’s a guide to who is taking care of prior authorization for your plan. Check your ID card to match the information with what you see here:
2024 Medicare Advantage PlansBENEFIT PLAN NAME and PLAN ID# MEMBER ID PREFIX PRIOR AUTHORIZATION REQUIREMENTS Blue Best Life Classic (HMO)
H002-006 in Maricopa and Pinal countiesM2K AZ Blue (and eviCore)
AZ Blue Prior Authorization List
Part D FormularyBlue Best Life Plus (HMO)
H0302-001 in Maricopa and Pinal countiesBlue Best Life Classic (HMO)
H0302-008 in Pima CountyBlueJourney (PPO)
H5140-001 or H5140-002 in Maricopa and Pima countiesM3P Note: All of our Medicare Advantage benefit plans require notification and/or prior authorization for inpatient admissions. Notification of unscheduled admissions is required within 24 hours of admission or by the next business day.The medical polices we use are based on the latest science and technology, medical literature, and evidence-based clinical data. For your plan, we use the following medical policies are used to determine the medical necessity of a service or medication.