Medical Coverage Policy — Drugs Requiring Prior Authorization
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Defines prior authorization requirements and submission processes for drugs covered under BCBSRI Medicare Advantage and Commercial medical plans, and notes where benefit variations may apply. Affects contracted providers submitting pre-service or retroactive prior authorization requests for covered drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior Authorization Requirement
Covered when prior authorization is obtained for drugs listed in the Coding section and benefits apply under the member's plan.
Submit pre-service requests via the vendor; see provider actions for portal and contact details.
Authorization through the BCBSRI Medical Drug Management vendor is required for drugs listed in the Coding section when benefit coverage applies. This authorization requirement does not apply to services rendered in an emergency room, observation, or inpatient setting.
Coding — Drugs Requiring Prior Authorization
| unlisted | Unlisted drug codes must be filed with the unlisted code and the NDC |
Provider Actions & Submission Instructions
Submit Prior Authorization via GatewayPA or Prime Therapeutics Management
Prior authorization is required for drugs listed in the Coding section. Submit pre-service requests via the GatewayPA portal at https://www.GatewayPA.com. For retroactive requests or questions, contact Prime Therapeutics Management at 1-833-895-8282 or fax requests to 1-888-656-6671. Note: the GatewayPA portal is for contracted providers only; non-contracted providers should call or fax requests.
- GatewayPA portal: https://www.GatewayPA.com
- Phone for Prime Therapeutics Management: 1-833-895-8282
- Fax for retroactive requests: 1-888-656-6671
- GatewayPA portal is for contracted providers; non-contracted providers must call or fax
Follow NCD/LCD for Coverage and Prime Therapeutics for Dosing
For Medicare Advantage plans, use applicable NCD/LCD criteria when evaluating requests; dosing determinations follow Prime Therapeutics Management policies. Unlisted codes should follow the product labeling.
- NCD/LCD criteria apply for Medicare Advantage Plans
- Dosing governed by Prime Therapeutics Management policies
- Unlisted codes follow product labeling
Claim Filing for Unlisted Codes, NDCs, and Specialty Pharmacy Sourcing
When a drug has only an unlisted code, file the claim with the unlisted code and include the NDC. If the drug is obtained from Walgreens Specialty Pharmacy, submit the claim with the appropriate administration CPT code instead of the drug HCPCS code.
- File unlisted-code drugs with the unlisted code plus the NDC
- If sourced from Walgreens Specialty Pharmacy, bill the administration CPT code (not the drug HCPCS)
Risk of Denial Without Prior Authorization
Claims for drugs listed in the Coding section that do not have prior authorization may be denied or subject to benefit limits.
- Ensure prior authorization is obtained before service to avoid denial or benefit limitations
Site of Care Exceptions
Authorization Not Required for ER, Observation, or Inpatient Settings
The prior authorization requirement does not apply when drug services are provided in the emergency room, during observation, or in an inpatient setting.
- No prior authorization needed for ER, observation, or inpatient drug services
Background
For clinical guidelines that determine medical necessity and prior authorization approvals for drugs covered under this policy, providers should consult the plan’s Drug Management Program vendor, Prime Therapeutics Management / GatewayPA.
Definitions
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