What Does it Mean to Need Prior Authorization?

As a BMC HealthNet Plan member, you may need approval for certain procedures, medicines, or visits to doctors who are outside of our network. This process is called prior authorization or prior approval. Your Member Handbook includes a list of your benefits, and will tell you whether you need approval for a certain treatment or drug.

We use this process to make sure that you get only the care that you really need. If your service requires prior approval, your doctor will contact us on your behalf to request it, and we will work with your doctor to make sure that it is appropriate for you to get that service.

Here are a few things we consider when we review requests for prior approval:

For a procedure or service

  • Are there treatments that could be more beneficial to you?
  • Are there other treatments to try first?
  • Is this treatment experimental?
  • Is this treatment essential for your medical condition?

For medicine

  • Are there generic drugs available that have the same effect?
  • Is this drug new? Does it have proven benefits?
  • Is there another drug that should be tried first?

For providers who are out of our network

  • Is there a provider in our network who can offer a similar treatment?
  • Is there a provider who is located closer to you?