• Make sure you're covered

    Don’t be surprised by a bill you weren’t expecting

    About Prior Authorization

    Did you know that you may be required to get an approval for coverage from your health plan before you have a planned medical service or procedure? This is called a prior authorization, and it helps you:

    • Find out if you’re covered by your benefits before you have your scheduled procedure
    • Save money and avoid extra costs
    • Get an estimate of your out-of-pocket costs before you get your service
    • Avoid unnecessary services

    If your health plan does not have a prior authorization requirement, then we recommend that your doctor request a benefit advisory before scheduling a planned medical procedure to see if it is eligible for coverage. Learn more about benefit advisories 

    If your health plan does require a prior authorization for some services…

    Your doctor should request a prior authorization for you

    Your healthcare provider is familiar with the process for getting a prior authorization. So, it’s best if your doctor contacts Premera on your behalf. Your doctor has all of the medical information needed to ask that your medical service be reviewed and approved for coverage.

    What happens if your doctor doesn’t request a prior authorization

    If your doctor gives you a service that requires a prior authorization without requesting one, you may have to pay extra costs. Refer to your benefit booklet to see your medical benefits and prior authorization requirements.

    To avoid extra costs always ask your healthcare provider to request a prior authorization before you have a planned medical service. 

    The list below shows some services and procedures that require a prior authorization. 

    Some services that require a prior authorization*

    • Planned admission into hospitals or skilled nursing facilities
    • Non-emergency ground air or ambulance transport
    • Transplant and donor services
    • Some planned outpatient procedures
    • Some injectable injectable medications you get in a healthcare provider’s office
    • Prosthetics and orthotics other than foot orthotics or orthopedic shoes
    • Reconstructive surgery
    • Homemedical equipment costing $500 or more
    • Some prescription drugs require a prior authorization review to approve coverage.
      Learn more about drugs requiring approval.

    *This is not a complete list. Your doctor has the most current list and medical information needed to request a prior authorization on your behalf.

    Services that do not require a prior authorization

    • Hospital admission for childbirth and newborn care
    • Emergency admission to hospital

    Questions?

    Call customer service at the number on the back of your Premera member ID card.