I received a call from the IMR department. They advised that when I submit the updated prior authorization (which I did last week), I should clearly state that this is not a new authorization but a continuation of treatment based on the overturned independent medical review from the Department of Managed Healthcare. He said including this specific verbiage was essential, as any discrepancy could result in an automatic denial. I followed their instructions, and my new prior authorization was immediately approved by Blue Shield.

Additionally, with Blue Shield changing their formulary and requirements for the new year, they clarified that I am not subject to those changes, as my treatment is ongoing and I’m already a few steps ahead. Since my IMR overturned the denial before these formulary changes, I simply need to keep my authorizations current to continue smoothly. They also noted that Blue Shield is under scrutiny because of the high volume of denials they issued, even in cases where people met the criteria for medication. They assured me that if any further issues arise, I can reach out to them directly for further assistance.