Prior Authorization Changes for Some Commercial and Government Program Members

Sept. 30, 2026

We’re changing prior authorization requirements that may apply to some commercial and government program members.

Changes are based on updates from utilization management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System code changes from the Centers for Medicare & Medicaid Services.

For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Montana. Utilization management and related services for members with Medicaid will be reviewed by Carelon Medical Benefits Management. Utilization management and related services for members with Medicare Advantage will be reviewed by BCBSMT and EviCore healthcare. Carelon Medical Benefits Management and Alacura Medical Transportation Management will review utilization management and related services for some commercial members.

Note: Effective Jan. 1, 2027, we will begin reducing recommendations that you complete a Recommended Clinical Review. We expect to remove this option entirely from our utilization management processes for most commercial members by the end of 2027. Learn more about this utilization management program change for commercial members.  

Review the upcoming changes by impacted members and effective dates below.

Commercial – Jan. 1, 2027:  

  • Addition of genetic testing codes to be reviewed by Carelon
  • Removal of genetic testing codes previously reviewed by Carelon
  • Transfer of miscellaneous codes from recommended clinical review to prior authorization to be reviewed by BCBSMT
  • Addition of medical oncology therapy codes to be reviewed by Carelon
  • Addition of provider administered drug codes to be reviewed by Carelon

Commercial – Oct. 1, 2026: 

  • Addition of medical oncology drug codes to be reviewed by Carelon

Medicare – Jan. 1, 2027:  

  • Addition of oncology drug, orthotics, wound care and durable medical equipment codes to be reviewed by BCBSMT
  • Miscellaneous changes to the Part B Step Therapy Program

See our revised lists of codes. 

CPT copyright 2025 AMA. CPT is a registered trademark of the AMA.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. EviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSMT. Carelon Medical Benefits Management is an independent company that has contracted with BCBSMT to provide utilization management services for members with coverage through BCBSMT.