Medical-benefit prior authorization for specified drugs (MDR Drug Listing)
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Notifies Medicare Advantage members and providers that, effective July 1, 2020, an expanded list of drugs administered under the medical benefit will require prior authorization handled by Prime Therapeutics for BCBSRI members; applies to office and hospital outpatient administrations.
An expanded list of drugs that may be covered under the medical benefit for Medicare Advantage plans will require prior authorization effective July 1, 2020.
Coverage Criteria
This notice clarifies that the listed medications are covered under the medical benefit and are generally administered in a provider setting (e.g., a doctor’s office or hospital outpatient clinic). These drugs are distinct from Medicare Part D pharmacy-dispensed medications that members pick up at a retail pharmacy.
Provider Actions Required
Prior Authorization Required
Prior authorization is required for the expanded list of drugs administered under the medical benefit for Medicare Advantage plans effective July 1, 2020. Prior authorizations will be handled by Prime Therapeutics, LLC.
- Effective date: July 1, 2020
- Applies to drugs listed in the MDR Drug Listing (effective 7/1/20)
How to Submit Prior Authorization Requests
Requests for prior authorization must be submitted to Prime Therapeutics, LLC. Requests may be made by the provider, the member, or the member's representative.
- Phone: 1-800-693-6651 (TTY: 711)
- Fax: 855-212-8110
- Online: www.myprime.com
- Mail: Prime Therapeutics, Attn: Part B Benefit Requests, 2900 Ames Crossing Rd., Eagan, MN 55121
- Hours: 24 hours a day, 7 days a week
Step Therapy
No step therapy rules are specified in this document; the listing identifies drugs that will require prior authorization but does not impose step therapy requirements.
Timing of Requests
Requests for prior authorization submitted before July 1, 2020 cannot be received and therefore will not be processed.
Site of Care / Applicability
Site of care: office or hospital outpatient (medical benefit)
The drugs listed are typically those administered in a doctor's office or hospital outpatient clinic and are covered under the medical benefit; prior authorization applies when administration is billed under the medical benefit.
Definitions
Background
This letter informs providers and members that, effective July 1, 2020, BCBSRI will require prior authorization for an expanded list of drugs billed under the medical benefit for Medicare Advantage plans. Prior authorizations will be processed by Prime Therapeutics, LLC beginning on that date; requests submitted before July 1, 2020 will not be received or processed. Providers, members, or their representatives must contact Prime Therapeutics to request prior authorization by phone at 1-800-693-6651 (TTY: 711), fax at 855-212-8110, online at www.myprime.com, or by written letter to Prime Therapeutics, Attn: Part B Benefit Requests, 2900 Ames Crossing Rd., Eagan, MN 55121.
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