CareFirst Prior Authorization Lookup
Latest CareFirst prior authorization updates16
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Hospice ServicesDefines CareFirst coverage stance for hospice and palliative care services for terminally ill members including levels of care (routine home, inpatient, continuous home care, respite), benefits, preauthorization requirement, and applicability relative to member contracts and clinical trials.All CareFirst updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Repository Corticotropin Injection (H.P. Acthar Gel) — RETIREDThis document governs coverage and administrative handling for repository corticotropin injection (H.P. Acthar Gel) and informs providers that the policy is retired; it affects providers submitting drug prior authorization requests to CareFirst.All CareFirst updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-02-01Specialty Drugs - Benefit Assignment and Prior Authorization ListingDefines the list of specialty drugs, their benefit assignment (medical vs pharmacy), prior authorization requirements, and therapeutic categories; applies to members whose plans include CareFirst benefits and to in-network specialty pharmacy fulfillment. Contact information for CVS Specialty is provided for access questions.All CareFirst updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Therapeutic ApheresisDefines medical necessity indications and experimental/investigational exclusions for therapeutic apheresis procedures; CareFirst adopts MCG Care Guidelines® for clinical criteria and requires checking member contract and prior authorization when applicable.All CareFirst updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Medical Drugs Requiring Prior Authorization (medical benefit)List of injectable and other medical drugs that require prior authorization through the CareFirst Provider Portal for CareFirst members; applies to providers submitting medical (J/C/Q) drug claims under CareFirst plans.All CareFirst updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-10-01Medical drugs requiring prior authorization (CareFirst CHPMD)This document lists medical drugs that require prior authorization from CareFirst BlueCross BlueShield Community Health Plan Maryland and governs providers submitting medical drug requests to the plan.All CareFirst updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-017.01.116 RETIRED Transcatheter Pulmonary Valve ImplantationDefines medical necessity and coverage criteria for transcatheter pulmonary valve implantation (TPVI) for members of CareFirst, aligning with MCG Cardiac Valve Replacement or Repair guidelines; affects providers submitting for TPVI and related prior authorization.All CareFirst updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Extracorporeal Shock Wave Lithotripsy (ESWL) for gallbladder and pancreatic stonesDefines medical necessity criteria and coverage stance for ESWL to treat gallstones, common bile duct stones, and pancreatic duct stones for CareFirst members; applies to providers submitting prior authorization and coverage requests.All CareFirst updates
- Prior AuthClinical/Medical PolicyEff. 2024-04-01Medical drugs requiring prior authorizationLists medical (J/Q/C) drugs that require prior authorization for CareFirst BlueCross BlueShield Community Health Plan Maryland members and maps certain miscellaneous HCPCS/J-codes. Affects providers submitting claims for these listed medical drugs.All CareFirst updates
- Prior AuthReimbursement/Payment PolicyEff. 2023-10-06Respiratory Syncytial Virus (RSV) Vaccination And Administration Billing GuidelinesGuidance for billing and coding of Respiratory Syncytial Virus (RSV) vaccines and their administration for CareFirst providers, including applicable CPT and ICD-10 codes and payer stance on prior authorization for specific products.All CareFirst updates
- Prior AuthClinical/Medical PolicyEff. 1998-04-01Air Fluidized BedsGoverns medical necessity and coverage criteria for air fluidized beds (HCPCS E0194) for treatment of pressure ulcers and extensive burns in non-ambulatory, bedridden patients; affects providers and prior-authorization processes for CareFirst members.All CareFirst updates
- Prior AuthClinical/Medical PolicyCosmetic and Reconstructive Surgery with Attached Companion TableDefines CareFirst coverage stance distinguishing cosmetic versus reconstructive surgical procedures, documentation review process, prior authorization note, and that reconstructive surgery is medically necessary while cosmetic is not; applies to members and providers under CareFirst benefit plans.All CareFirst updates
- Prior AuthClinical/Medical PolicyMedical Injection Preauthorization Request Form (Prior Authorization Instructions)Form and instructions governing prior authorization requests for medical injections (infusion or injection services) submitted to CareFirst BlueCross BlueShield Community Health Plan Maryland; affects providers requesting authorization for outpatient, inpatient, or home infusion/injection services for members.All CareFirst updates
- Prior AuthClinical/Medical PolicyMedical Preferred Drug List (PDL) — outpatient step therapy and preferred/non-preferred drug designationsDefines CareFirst CHPMD's Medical Preferred Drug List for outpatient medications, specifying preferred and non-preferred biologic and specialty drugs and that prior authorization and step therapy apply for non-preferred agents. Affects providers prescribing outpatient specialty and medical drugs for CareFirst CHPMD members in Maryland.All CareFirst updates
- Prior AuthClinical/Medical PolicyMedical Preferred Drug List — Outpatient Step Therapy and Prior AuthorizationDefines preferred and non-preferred medications and step therapy/prior authorization expectations for outpatient medications under CareFirst CHPMD; affects providers prescribing covered drugs to plan members in Maryland.All CareFirst updates
- Prior AuthClinical/Medical PolicyTransgender ServicesThis retired operating procedure governed coverage and prior authorization for transgender services (medical counseling, behavioral health, hormone therapy, and gender-affirming surgeries) when benefits exist in a member's contract; it applied to CareFirst members and providers submitting requests for authorization.All CareFirst updates
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Tool Description
Search CareFirstprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Prior Authorization by Payer
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Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
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