New prior authorization vendor and effective date

Beginning August 15, 2025, Prime Therapeutics Medical Pharmacy Solutions will perform prior authorization reviews for the listed medical-benefit drugs; providers must obtain PA from Prime for services on/after this date. Providers may begin contacting Prime on August 7, 2025 for treatments starting on or after August 15, 2025.

• Contact Prime beginning 2025-08-07 for treatments on/after 2025-08-15
• Effective date: 2025-08-15

How to submit PA requests

Providers must submit PA requests for in-scope medical-benefit drugs to Prime via GatewayPA.com for routine requests. Urgent, expedited, or retroactive requests must be phoned to Prime at 800-424-1713. Providers previously using CoverMyMeds and/or fax to request medical-benefit drug reviews must change workflows and begin submitting reviews to Prime's Medical Pharmacy Solutions team.

• Routine requests: GatewayPA.com (portal for routine requests)
• Urgent/retroactive/expedited requests: call Prime Operations at 800-424-1713 (Prime has staff available 24/7 for urgent requests)
• This replaces prior CoverMyMeds/fax workflows for medical-benefit drug reviews

Required information for PA requests

PA requests must include provider, member, medication, and clinical information as detailed below. Include complete ordering and rendering provider details, member demographics, medication administration details (including place of service and HCPCS/drug), dosing and timing, and supporting clinical documentation.

• Ordering/rendering provider: name, Tax ID (TIN), practice address, office telephone and fax
• Member demographics: member name, date of birth, member ID number, height, weight, diagnosis code
• Medication details: place of service code, requested drug name or HCPCS code, dosage, frequency, anticipated start date of treatment
• Clinical documentation examples: clinical notes, pathology reports, relevant test results

Transition of care and authorization continuity

Authorizations issued by BCBSKS for dates of service before August 15, 2025 remain effective until their stated end date. To continue treatment after an authorization expires, providers must obtain a new authorization from Prime prior to the authorization end date. Claims for dates of service after the authorized end date will be denied if a successive authorization from Prime has not been obtained.

• Operational note: claims for dates after the authorized end date will be denied if successive authorization from Prime is not obtained prior to expiration

Prime review escalation process

If additional detail is needed during review, the case will be routed to a Prime pharmacist for provider outreach. Cases may be escalated to a Prime physician who will discuss the case with the ordering provider.

• Escalation path: Prime pharmacist outreach, then Prime physician escalation if needed