Florida Blue’s approach to prior authorizations

July 28, 2025

As a health insurance provider, Florida Blue’s primary goal is to ensure that our members receive safe, evidence-based, and affordable care. One way we achieve this is through our prior authorization process. Prior authorization is a valuable tool that protects our members and promotes high-quality care. In this blog post, we'll explore the benefits of prior authorization and how Florida Blue is innovating, leading and collaborating to make the process smoother for everyone.

What is prior authorization?

A prior authorization is when a health care provider asks us to confirm coverage and approve a treatment or medication before it's given to a patient. This is different from a claim, which is a request for payment after the treatment or service is provided. Think of it like this: a prior authorization is a request for treatment before a service, while a claim is submitting a bill for the treatment after it's been completed.

It is important to note that prior authorization is only selectively used. In fact, the vast majority of claims – 96% of prescription drug claims and 93% of medical claims – are not subject to prior authorization¹. For the rest of these claims, prior authorization serves as an important safety check for patients, helping to prevent inappropriate or dangerous use of certain prescription drugs or treatments.

Benefits of prior authorization

Prior authorization offers several benefits, including:

1. Ensures members get the right care: We review treatments, medications, and procedures to ensure they're supported by evidence-based, clinical guidelines. This reduces the risk of members receiving unnecessary or ineffective care.
2. Keeps members safe: We protect members from potentially unsafe or experimental treatments by having a health care professional review certain requests before proceeding.
3. Saves members money: Prior authorizations help prevent members from being billed for expensive treatments that may not be covered by their plan and promote evidence-based, cost-effective alternatives.
4. Supports health insurance affordability: Prior authorizations reduce fraudulent claims, keeping health care costs more manageable for all members in the plan.

Improving the prior authorization process

At Florida Blue, we want to make health care easier to navigate and as affordable as possible for our members. One way we're doing this is by improving the prior authorization process.

In June 2025, we joined other health insurance companies and organizations in an industry-wide commitment to make the prior authorization process faster, simpler, and more efficient. There are six health plan commitments to achieve this goal. Here's what they are and how Florida Blue is working to improve prior authorization:

1. Making Electronic Prior Authorization Easier: Creating a standardized way to send and receive prior authorization requests electronically will help speed up the process. Florida Blue is already using Artificial Intelligence (AI) and advanced technology to speed up and improve the process. Since 2022, we’ve processed over 2.5 million pre-approvals with a median response time of just 19 seconds.*
2. Reducing the Number of Services That Need Prior Authorization: We regularly review the services that require prior authorization and try to reduce or remove the requirement for services that are usually approved. We'll make even more changes by 2027.
3. Helping Patients Keep Their Care When They Switch Insurance: Starting January 1, 2026, if a patient switches insurance companies during treatment, the new insurance company will honor the existing prior authorization for the same services for 90 days. This will help patients avoid delays and keep getting the care they need.
4. Making It Clearer Why a Request Was Denied: We'll provide clearer explanations if a prior authorization request is denied, including information on how to appeal the decision. This starts January 1, 2026, for most insurance plans.
5. Getting Faster Answers: By 2027, at least 80% of electronic prior authorization requests will be answered in real-time². Florida Blue is already doing this, and we'll keep working to make it even better.*
6. Making Sure Medical Professionals Review Denied Requests: If a prior authorization request is denied for medical reasons, it will then be reviewed by a medical professional. This is already Florida Blue’s standard practice, and we'll keep doing it.

You can learn more about these changes and how they'll affect patients and healthcare providers at www.bcbs.com/ImprovingPA.

More facts about prior authorization at Florida Blue

Here are some surprising facts about prior authorization at Florida Blue:

• Only 8% of medical and pharmacy claims we receive are reviewed through the prior authorization process, streamlining the process for health care providers and patients.*
• 90% of prior authorizations are reviewed and approved in seconds, supported by automation and AI solutions.*
• AI cannot deny a prior authorization request. If the AI system is unable to approve a request at Florida Blue, it's forwarded to a specialist for further review. This ensures that every request receives a thorough review by a qualified medical or pharmacy specialist if needed.
• For denied authorizations, members have the right to appeal, and in certain cases, can request a federal external review.

In conclusion, prior authorization is a valuable tool that protects our members and promotes high-quality care. By understanding the benefits and facts about prior authorization at Florida Blue, we hope to dispel common misconceptions and provide our members with peace of mind.

¹Based on a 2024 survey of AHIP’s Commercial health plan members.

²AHIP. (2025, June 23). Health Plans Take Action to Simplify Prior Authorization. [Press release].

*Based on internal data
A prior authorization is not a guarantee of payment. Deductibles, coinsurance, and copays may still be applicable.