ModifiedBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Pharmacy Prior Authorization Program transition to Prime Therapeutics

Announces that effective May 1, 2026, certain specialty drugs under the medical benefit for BCBSRI members (Commercial, HIM/Exchange, Medicare) will require prior authorization and will be administered by Prime Therapeutics' Medical Pharmacy Solutions team; providers must obtain authorizations via GatewayPA.com or phone beginning April 24, 2026 for services on/after May 1, 2026.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Pharmacy Prior Authorization Program transition to Prime Therapeutics

Policy CodePolicy N/A

Change TypeMODIFIED

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain prior authorization for in-scope medical benefit specialty drugs through Prime Therapeutics (GatewayPA.com or phone 833-895-8282) for services on/after 2026-05-01; begin contacting Prime on/after 2026-04-24.

POLICY UPDATE CHANGES

Prime Therapeutics Medical Pharmacy Solutions will administer prior authorizations for specified medical-benefit specialty drugs effective 2026-05-01.

Submission workflow for medical benefit drug reviews changes from Prime Pharmacy Benefit Team (CoverMyMeds/fax) to Prime Medical Pharmacy Solutions via GatewayPA.com/phone for in-scope drugs.

3Impacted plan types

2026-05-01Program effective date

2026-04-24Provider contact start date

What is changing

Blue Cross Blue Shield of Rhode Island (BCBSRI) is transitioning administration of prior authorizations for certain medical-benefit specialty drugs to Prime Therapeutics' Medical Pharmacy Solutions team. The program is effective 2026-05-01, and providers may begin contacting Prime starting 2026-04-24 to obtain prior authorizations for treatments beginning on or after 2026-05-01.

The change impacts members enrolled in Commercial, HIM (Exchange), and Medicare plans. Scope: specified specialty drugs under the medical benefit listed on the BCBSRI Commercial Drug List or Medicare Advantage Drug List will require prior authorization and will be administered by Prime; providers must obtain authorizations via GatewayPA.com or phone beginning 2026-04-24 for services on/after 2026-05-01.

Program effective date2026-05-01

Provider contact start date2026-04-24

Impacted plan typesCommercial; HIM (Exchange); Medicare

Program applicability

Program Applicability

The program applies when ALL of the following are met:

ALL of the following

Impacted member enrollment: Member is enrolled in one of the impacted plans: Commercial, HIM (Exchange), or Medicare
In-scope medication: Medication is an in-scope specialty drug under the medical benefit as listed on the in-scope drug lists (Commercial Drug List or Medicare Advantage Drug List)
Effective date: Date of service for the medication is on or after 2026-05-012026-05-01

Prior authorization timing & submission

Prior Authorization Timing and Submission

Authorization requirements:

ALL of the following

Prior authorization timing: Prior authorization must be obtained before services are provided
Providers are responsible for ensuring authorization was obtained prior to services being rendered (see provider responsibilities).
Provider contact start date: Providers may begin contacting Prime for prior authorizations on or after 2026-04-24 for treatments starting on or after 2026-05-012026-04-24
Submission channels: Requests for in-scope medical benefit drugs must be submitted to Prime's Medical Pharmacy Solutions team via GatewayPA.com or by phone at 833-895-8282
Submission exceptions
- Self-administered drugs: Drugs typically self-administered by the patient continue to be requested through CoverMyMeds and/or fax
- Retrospective requests must be phoned in to the Prime Operations Team at 833-895-8282

Prior Authorization

New prior authorization vendor and process

Obtain prior authorization for in-scope medical benefit specialty drugs through Prime Therapeutics (GatewayPA.com or phone 833-895-8282) for services on/after 2026-05-01; begin contacting Prime on/after 2026-04-24.

Billing Rule

Retrospective and urgent request handling

Retrospective requests and urgent Medicare 1st level appeals must be phoned to Prime at 833-895-8282.

Required information on authorization request

Required Information on Authorization Request

Requests must include ALL of the following:

ALL of the following

Ordering provider: Ordering Provider Name
Tax ID
Practice address: Practice Address
Office contact: Office Telephone and Fax
Rendering provider: Rendering Provider information if different from Ordering Provider
Member identifiers: Member Name, Date of Birth, Member ID Number
Height and weight: Height and Weight
Diagnosis code: Diagnosis Code
Place of service: Place of Service Code
Requested drug: Requested Drug Name or HCPCS Code
Dosage
Frequency
Anticipated start date: Anticipated Start Date of Treatment
Clinical documentation
- Clinical notes
- Pathology reports
- Relevant test results

Documentation Required

Required request documentation

Include provider identifiers, member demographics, diagnosis code, place of service, requested drug name or HCPCS code, dosage, frequency, anticipated start date, and relevant clinical documentation.

Transition of care & claim risk

Transition of Care

ALL of the following

Existing BCBSRI authorizations: Authorizations issued by BCBSRI for dates of service before 2026-05-01 remain effective until their authorization validity end date
Obtaining successive authorization: To continue treatment after the original authorization validity end date, obtain an authorization from Prime prior to the expiration date
Denial risk: Claims for dates of service after the authorization validity end date may be denied if no successive authorization from Prime is obtained

Denial Risk

Risk of claim denial without successive authorization

Claims for dates of service after a BCBSRI authorization's validity end date may be denied if a successive authorization from Prime is not obtained prior to expiration.

Definitions & FAQs

In-scope drugs: Medications listed on the BCBSRI Commercial Drug List or Medicare Advantage Drug List that are included in the Prime Medical Pharmacy Prior Authorization Program.

Q: Where do providers submit prior authorization requests for in-scope medical benefit drugs? A: Submit via GatewayPA.com or by phone to Prime Therapeutics at 833-895-8282; drugs that are typically self-administered by the patient continue to be requested through CoverMyMeds and/or fax.

Q: When must providers begin contacting Prime for authorizations? A: Providers may begin contacting Prime on or after April 24, 2026 for treatments starting on or after May 1, 2026.

Policy update changes

2026-05-01material_change_effectiveLatest

Prime Therapeutics Medical Pharmacy Solutions will administer prior authorizations for specified medical-benefit specialty drugs effective 2026-05-01.

2026-04-24material_change_provider_contact_start

Submission workflow changes to Prime Medical Pharmacy Solutions via GatewayPA.com/phone; providers may begin contacting Prime starting 2026-04-24 for services on/after 2026-05-01.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Pharmacy Prior Authorization Program transition to Prime Therapeutics

Policy CodePolicy N/A

Change TypeMODIFIED

Effective DateMay 1, 2026

Next Review Date

On This Page

OpenPayer

Medical Pharmacy Prior Authorization Program transition to Prime Therapeutics

What is changing

Program applicability

Prior authorization timing & submission

Required information on authorization request

Transition of care & claim risk

Requested drug codes and coding notes

Definitions & FAQs

Policy update changes