Prior Approval

Helping you understand the prior approval process.

CORONAVIRUS UPDATE: FEP will waive prior authorizations for medically necessary diagnostic tests and covered services that are consistent with CDC guidance if diagnosed with COVID-19. Learn more here.

In some situations, you need to get your care, treatment or prescription drugs approved before we cover them. This is called prior approval, precertification or preauthorization.


MEDICAL SERVICES

Certain medical services and treatments need approval before you receive care. We review them to ensure they are medically necessary. If you do not obtain prior approval, there may be a reduction or denial of your benefit.

These medical services may require prior approval:

  • Inpatient hospital admission
  • Inpatient residential treatment center admission
  • Skilled nursing facility admission
  • Other services, including but not limited to:
    • Radiology (MRI, CT scans, PET scans)
    • Hospice care
    • Gene therapy and cellular immunotherapy
    • BRCA testing and testing for large genomic rearrangements
    • Organ/tissue transplants

You can see a full list of medical services that need to be approved in Section 3 of the Service Benefit Plan brochures.

In most cases, your physician or facility will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your provider if they have contacted us and provided all the necessary information. You can call the precertification number on the back of your member ID card to see if we have received the request.

PRESCRIPTION DRUGS

Some prescription drugs and supplies need approval. We need to confirm two things:

  • You’re using the drug to treat something we cover
  • Your doctor prescribes it in a medically appropriate way

You can see the full list of prescription drugs that need to be approved on the CVS Caremark website.

Your doctor can submit prior approval electronically, by fax or by mail. Forms and additional information can be downloaded on the CVS Caremark website.

Thank You for Being a Caregiver
We pledge to honor and support all caregivers who are vitally needed at this time. Because we’re in this together. You can learn more here.

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