approvals & authorizations
What is a Pre-Service Review and What Treatments Require It?
A pre-service review may be called a prior approval, a prior authorization or both, but rest assured, this process helps us make sure you get the best care.
What is a prior approval?
Before prescribing certain treatments, your doctor contacts us for prior approval. Treatments like MRIs or chemical peels may require prior approval. Treatments like most blood tests or setting a broken arm usually do not.
You can find a complete list of those treatments on the Wellmark Authorization Table.
What is a prior authorization?
Drugs that treat chronic or complex conditions, like hepatitis C or rheumatoid arthritis, may require prior authorization before they’re eligible for benefit coverage. These drugs are usually very expensive and require special handling and storage. So it’s a little different than just picking up an antibiotic at the corner pharmacy.
You can find a complete list of drugs that require prior authorization on our Pharmacy Prior Authorization List.
What happens during a pre-service review?
Each plan has its own rules. We look at generic alternatives if your doctor prescribes a brand-name drug. For certain procedures, we determine if the procedure is medically necessary and follows nationally approved guidelines. Additionally, for certain types of recommendations, like admission to an out-of-state hospital, we require doctors to request precertification.
We make our decisions very carefully, using data from peer-reviewed scientific literature and guidelines developed by other health care organizations. With the intent of reducing costs for all members, we regularly update the Wellmark Drug List of covered drugs with a committee of statewide pharmacists and physicians.
Similarly, we evaluate new medical technologies. We ask, “Has it been approved by the appropriate governmental regulatory body?” or “Is the new technology as beneficial to the patient as more established technologies?”
The time it takes to make approvals depends on the urgency of the situation. Your doctor tells us if it’s a normal request or one that requires immediate attention. Just know that we are working to not only approve your doctor’s recommendation, but approve it quickly.
Once approved, your approval or authorization is valid for a certain length of time, usually 90 days. After that, a new approval is required. If your procedure is not approved, however, it doesn’t mean you can’t have the procedure, it just means your plan may not cover it.Learn More