Medical Pharmacy Program — Prior Authorization for Specialty Medications
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Describes BCBSRI's Medical Pharmacy Program administered by Prime Therapeutics to manage prior authorizations for certain specialty medications under the medical benefit for Commercial, HIM (Exchange), and Medicare members effective May 1, 2026.
A new Medical Pharmacy Program administered by Prime Therapeutics will manage prior authorizations for certain specialty medications under the medical benefit.
Coverage and Authorization Rules
Covered when criteria per Prime posted policies are met
Coverage and medical policy criteria are defined on Prime's site for medications included in the program.
See GatewayPA.com for drug-specific criteria and approval durations.
Authorizations issued by BCBSRI with dates of service before May 1, 2026 for medications included in the Medical Pharmacy Program remain effective through their original authorization end date. To continue therapy beyond that end date, providers must obtain a successive authorization from Prime prior to the expiration date. Claims for dates of service after an authorization end date will be denied if a successive authorization from Prime is not obtained.
What Providers Must Do
Prior authorization required — request via Prime portal or phone
Prior authorization is required for medications listed on Prime's GatewayPA.com. Providers may request non-urgent authorizations via the Prime secure provider portal at www.GatewayPA.com or by phone at 833-895-8282 (hours 8am–6pm EST for routine requests; 24/7 for urgent requests). The ordering provider is responsible for obtaining prior authorization before services are provided; if ordering and rendering providers differ, the rendering provider must ensure an approval is on file prior to rendering services.
- Use GatewayPA.com to identify program-included medications and access the Prime portal.
- Phone requests: 833-895-8282 (routine 8am–6pm EST; urgent 24/7).
- Ensure member and provider identifiers, medication/HCPCS code, dosing, anticipated start date, and diagnosis are included with the request.
Prime manages PAs — authorization must be on file before administration
Prime Therapeutics oversees utilization management for the program; prior authorizations must be on file with Prime before rendering providers administer medications. Claims continue to be submitted to BCBSRI.
- Obtain and confirm active Prime authorization prior to administration.
- Submit claims to BCBSRI as usual; Prime manages the authorization, not claims processing.
Check GatewayPA.com for medication lists and step therapy rules
Refer to the medication list and medical policy criteria posted on GatewayPA.com for which drugs are included in the program and for any step therapy or drug-specific requirements.
- GatewayPA.com contains the current medication list and medical policy criteria; the list is updated at least annually.
When requested, submit supporting clinical documents to Prime
If Prime requests supporting clinical documentation during the authorization review, providers must upload documents to the Prime provider portal or fax them to Prime's HIPAA-compliant fax as instructed.
- Be prepared to provide clinical notes, pathology reports, and relevant lab test results.
- Include member identifiers, provider details, medication or HCPCS code, dosing, anticipated start date, and diagnosis (ICD-10) with the submission.
Required documentation for PA — clinical notes, pathology, labs
Providers should be prepared to upload or fax clinical notes, pathology reports, and relevant lab test results if requested by Prime; include member identifiers, provider details, medication/HCPCS code, dosing, anticipated start date, and diagnosis (ICD-10).
- Upload documents via the Prime secure provider portal or fax to Prime's HIPAA-compliant fax line as instructed.
- Ensure complete patient and provider identifiers are included to expedite processing.
Appeal instructions on EOB when PA was not obtained
When prior authorization was required but not obtained, providers can follow the instructions on the Explanation of Benefits (EOB) to submit a claim appeal as applicable.
- Review the EOB for appeal submission steps and required supporting information.
- Prime manages first-level appeals related to utilization management decisions.
Claim denial risk when authorization has expired
Claims for dates of service after an authorization end date will be denied if a successive authorization from Prime is not obtained prior to the expiration date.
- Obtain successive Prime authorization before the current authorization end date to avoid claim denials.
- Existing BCBSRI-issued authorizations for dates of service before May 1, 2026 remain effective until their original end date; after that, successive authorization must come from Prime.
Rendering provider claim denial risk if ordering provider lacks PA
A claim submitted by the rendering provider will be denied if the ordering provider fails to obtain the appropriate prior authorization; rendering providers must confirm a Prime authorization is on file before administering medications.
- Rendering providers are responsible for verifying authorization status with Prime prior to service.
- If ordering and rendering providers differ, clarify who will secure the authorization and document confirmation.
Authorization Request Codes
| ICD-10 | Requested diagnosis code |
| HCPCS | Requested medication HCPCS code |
Transition and Continuation of Care
Continuation and transition of care — transition and changes during an approval period
Transition and changes during an approval period
Approval duration depends on medication and is not negotiable.
Place of Service Requirements
Prior authorization required at all places of service
Prior authorization is required for in-scope drugs at all places of service; obtain PA from Prime regardless of site where the medication will be administered.
- This requirement applies to home and all other places of service
Program Definitions
Policy Background
This document describes administrative implementation of utilization management for certain specialty medications under BCBSRI’s medical benefit, administered by Prime Therapeutics. Prior authorization for program medications must be requested through Prime via the Prime provider portal or by phone; providers should be prepared to provide member and provider identifiers, the requested medication/HCPCS code, dosing and anticipated start date, diagnosis (ICD-10), and supporting clinical documentation such as notes, pathology reports, and relevant lab results when requested.
Prime will manage prior authorizations and utilization review beginning May 1, 2026. Existing BCBSRI authorizations for dates of service before that date remain in effect until their original end date, but to avoid claim denials providers must secure successive authorizations from Prime before those approvals expire.
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