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MEDICARE ADVANTAGE

Prior Authorization and Medical Policies

How we help you make sure you’re getting the care you need.

  • AZ Blue uses the prior authorization review process to determine your eligibility for a requested procedure or medication before you receive it. It’s not a guarantee of payment.

    Our clinical staff (doctors and nurses) make authorization decisions on your eligibility, health condition, the specific benefits in your plan, and the clinical guidelines we use to determine if the recommended care is medically necessary for your situation.

    Note: The fact that a provider has prescribed, ordered, or recommended 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. Even if a service is authorized, we still review the claim and process it according to your plan coverage, including any limitations, exclusions, maximums, and waivers.

  • To find the prior authorization requirements for your plan, first check the back of your ID card. It will look like one of the three samples below. The name you see in yellow highlight on the left side of your card is who will take care of prior authorizations you might need for certain services. You can call the prior authorization number on your card, for more information or view the prior authorization lists in the links below. You can also ask your healthcare provider to check if prior authorization is needed for a recommended service or medicine.

    1. BCBSAZ (AZ Blue): 1-800-446-8331 | AZ Blue Prior Authorization List
    2. Optum Health Network Arizona (OHNAZ): 1-877-370-2845 | Optum Prior Authorization List
    3. Arizona Priority Care: 480-499-8720 | Arizona Priority Care Prior Authorization List

    If you are admitted for inpatient care, your provider must inform us within 24 hours or the next business day. Prior authorization may also be required for scheduled inpatient care.

  • We use medical policies to guide our decisions on prior authorizations and claims. Our policies are based on evidence-based clinical research. We carefully review new healthcare technology and scientific findings as they become available.

    For your Medicare Advantage plan, we use the following medical policies:

    Note: If you can’t find what you’re looking for, please call us at 1-800-446-8331.

    Blue Cross® Blue Shield® of Arizona (AZ Blue) is contracted with Medicare to offer HMO Medicare Advantage plans. Enrollment in AZ Blue plans depends on contract renewal.

    You are eligible to enroll in a AZ Blue Medicare Supplement plan if you are age 65 or older, entitled to Medicare Part A, and enrolled in Medicare Part B, and you live in the plan service area. You must continue to pay your Medicare Part B premiums (and Part A, if applicable), if not otherwise paid for by Medicaid or another third party. During the first six months when you are age 65 and also enrolled in Medicare Parts A & B you cannot be denied a Medicare Supplement plan when you apply for one, regardless of health status.

    Health Choice Pathway HMO D-SNP is a Health Plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Health Choice Pathway HMO D-SNP depends on contract renewal. Health Choice Pathway Member Services can be reached at 1-800-656-8991, TTY: 711, 8 a.m. to 8 p.m., 7 days a week.
    Member Services can be reached at 480-937-0409 (in Arizona) or at our toll-free phone number at 1-800-446-8331 (TTY users should call 711). Hours are 8 a.m. to 8 p.m., Monday through Friday from April 1 to September 30; and 7 days a week from October 1 to March 31. Member Services also has free language interpreter services available for non-English speakers.

    OptumRx® is an independent company providing prescription mail order services.

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    Last Updated 01/01/2025