Medical Pharmacy Prior Authorization Program
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Defines the Medical Pharmacy Program prior authorization requirements and operational processes for BCBSKS Commercial/Exchange members for medications administered under the medical benefit, managed by Prime Therapeutics' Medical Pharmacy Solutions team.
Prior authorization program for certain medical-benefit medications will be administered by Prime Therapeutics effective Aug. 15, 2025.
Coverage Criteria and Applicability
Program-level coverage conditions
Covered when ALL of the following are met
Medication list and clinical criteria available on GatewayPA.com; program effective Aug. 15, 2025
Prior authorization required for these places of service
Approvals are valid for network providers sharing the billing TIN; rendering provider must confirm approval is on file before administering medication
This program applies only to BCBSKS Commercial/Exchange members. Members who are not enrolled in BCBSKS Commercial/Exchange are not covered under this Medical Pharmacy Prior Authorization Program.
Claims for dates of service after an authorization end date will be denied if a successive authorization from Prime is not obtained. To continue treatment beyond an existing authorization’s end date, the provider must obtain a successive authorization from Prime prior to the authorization expiration.
Billing and Place-of-Service Codes
| POS 11 | Physician office |
| POS 12 | In home |
| POS 19 | Outpatient facility |
| POS 22 | Outpatient facility - distinct |
| POS 21 | Inpatient - CAR-T |
Provider Responsibilities and Operational Details
Prior Authorization Required
Certain medical-benefit medications listed on Prime's GatewayPA.com require prior authorization through Prime. Providers contracted with BCBSKS must request authorization via the Prime secure provider portal or by phone for urgent requests.
- Prior authorization required for medications listed on www.GatewayPA.com
- Request non-urgent authorizations via Prime provider portal at www.GatewayPA.com
- Call Prime at 800-424-1713 for urgent requests (24/7) or routine requests Mon-Fri 8 a.m.-6 p.m. EST
Updates and Clinical Criteria Location
The list of medications included in the Medical Pharmacy Program and the clinical policy criteria and guidelines are posted and maintained on Prime's website. The medication list and clinical criteria are updated at least annually; providers must refer to the current postings on GatewayPA.com for the most recent requirements.
- Medication list and clinical criteria posted on www.GatewayPA.com
- List and criteria updated at least annually — always refer to posted policies for current requirements
Required Information and Supporting Documents
To expedite prior authorization or re-authorization requests, providers should have member and provider identifiers, clinical details, and be prepared to upload supporting documents to the Prime portal or fax them to Prime's HIPAA-compliant fax if requested.
- Member name, date of birth and ID number
- Health plan name
- Member height and weight
- Ordering provider name, tax ID, NPI, practice address, phone and fax
- Rendering provider name, tax ID, NPI, practice address, phone and fax (if different)
- Requested medication name or HCPCS code and anticipated start date
- Dosing information and frequency; Diagnosis (ICD-10 code)
- Any additional pertinent clinical information
- If requested by Prime: clinical notes, pathology reports, relevant lab test results
Denial Triggers
Authorizations issued by BCBSKS for dates of service before Aug. 15, 2025 remain effective until their authorization end date. To continue treatment beyond that end date, obtain a successive authorization from Prime prior to expiration. Claims for dates of service after an authorization end date will be denied if a successive Prime authorization is not obtained. If the ordering provider fails to obtain prior authorization, claims submitted by the rendering provider will be denied; follow EOB instructions to appeal if applicable.
- Authorizations issued by BCBSKS for dates of service before 2025-08-15 remain valid until their end date
- Obtain successive Prime authorization before original authorization end date to avoid denials
- Claims for dates of service after the authorized end date will be denied without a new Prime authorization
- Rendering provider claims will be denied if the ordering provider did not obtain prior authorization; providers may follow EOB appeal instructions
Document Background and Scope
This document provides administrative guidance on the utilization management program and operational changes related to prior authorization administration. It does not provide clinical disease background; instead, it directs providers to obtain authorizations and follow the program procedures administered by Prime. Existing authorizations issued by BCBSKS before Aug. 15, 2025 remain effective until their original authorization end date, but providers must obtain successor authorizations from Prime before expiration to avoid claim denials.
Key Definitions
Continuation of Existing Authorizations
Continuation of existing authorizations
Existing authorizations issued before the program transfer remain effective as described below
To continue treatment after the original end date, obtain a successive authorization from Prime prior to expiration
Step Therapy Operational Process
| Step | Requirement / action |
|---|---|
| 1 | If a prior authorization request does not initially have sufficient evidence to be approved, Prime will pend the request for clinical pharmacist review. |
| 2 | If the initial clinical reviewer (a Prime clinical pharmacist) determines the request meets clinical criteria, the reviewer may approve the prior authorization. |
| 3 | If the clinical pharmacist cannot find sufficient evidence to approve the request, Prime will schedule a peer-to-peer conversation with a Prime physician (board-certified peer clinical reviewer) who will make the final determination. |
Site-of-Care Prior Authorization Requirements
Obtain PA for listed places of service (POS 11,12,19,22,21)
Prior authorizations are required for medications administered in physician offices, in-home, outpatient facilities (POS 19, 22), and for inpatient CAR-T (POS 21); ensure PA is obtained for these places of service before administration.
- POS 11 — Physician office
- POS 12 — In home
- POS 19 — Outpatient facility
- POS 22 — Outpatient facility - distinct
- POS 21 — Inpatient - CAR-T
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