CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prior Authorization of Drugs

Defines drugs that require prior authorization for BCBSRI Medicare Advantage and Commercial medical plans, directs providers to the Drug Management vendor (Prime Therapeutics/GatewayPA) for clinical criteria and submission, and lists procedural notes about coding and settings where PA does not apply.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization of Drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2026

Next Review Date

Key ActionSubmit pre-service prior authorization requests online via GatewayPA (https://www.GatewayPA.com) or fax to 1-888-656-6671; for retroactive requests call Prime Therapeutics Management at 1-833-895-8282.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

External listDrugs Requiring PA

MA & CommercialPlans Covered

ER/Obs/InpatientPA Exempt Settings

Coverage Summary

This policy defines drugs that require prior authorization for BCBSRI Medicare Advantage and Commercial medical plans and states the coverage stance as covered_with_criteria. Effective date: 06|01|2026; Last review: 02|04|2026. It directs providers to the contracted Drug Management vendor, Prime Therapeutics/GatewayPA, for clinical criteria and submission procedures and highlights that the list of drugs requiring PA is maintained externally. High-level statistics: Drugs Requiring PA: External maintained list; Plans Covered: Medicare Advantage & Commercial; PA Exempt Settings: Emergency/Observation/Inpatient.

Required Provider Actions

Prior Authorization

Use GatewayPA or fax for prior authorization

Submit pre-service prior authorization requests online via GatewayPA (https://www.GatewayPA.com) or fax the prior authorization form to 1-888-656-6671; for retroactive requests call Prime Therapeutics Management at 1-833-895-8282 or fax 1-888-656-6671.

Documentation Required

Follow vendor clinical guidelines

Provide documentation consistent with the Drug Management Program vendor's clinical guidelines; for Medicare Advantage, follow NCD/LCD criteria for coverage determinations except dosing which follows Prime Therapeutics policies.

Billing Rule

Unlisted codes and specialty pharmacy billing

When a drug has only an unlisted code, file the claim with the unlisted code and the NDC; if obtained from a specialty pharmacy, submit the claim with the appropriate administration CPT code rather than the drug HCPCS code.

Drugs Requiring Prior Authorization (Coding)

The list of drugs is an externally maintained Excel titled Drugs Requiring Prior Authorization (external maintained list) and is provided as a coding spreadsheet (link in the policy). Codes for these drugs are managed externally under a mixed coding system and operational/code maintenance is handled by BCBSRI in coordination with Prime Therapeutics/GatewayPA.

Drugs Requiring Prior Authorization (external maintained list)mixedCovered

No codes listed

Background and Definitions

This policy directs providers to Prime Therapeutics/GatewayPA (the contracted Drug Management vendor) for clinical guidelines, prior authorization submission, and handling of requests; online submissions use the GatewayPA portal and Prime Therapeutics manages retroactive requests and clinical criteria. The authorization requirement does not apply to services rendered in an emergency room, observation, or inpatient setting. Benefits and specific coverage can vary by group/contract, so providers should refer to the member's Evidence of Coverage or Subscriber Agreement for applicable physician-administered drug benefits.

Definitions

Operational Notes