CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prior Authorization of Drugs

Defines drugs covered under BCBSRI Medicare Advantage and Commercial medical plans that require prior authorization and directs providers to the Drug Management vendor for submission and clinical review. Affects contracted (and non-contracted with different submission instructions) providers submitting medical/drug-administered claims.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization of Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateApr 2, 2026

Key ActionSubmit prior authorization requests via GatewayPA (https://www.GatewayPA.com) or by calling/faxing Prime Therapeutics Management (1-833-895-8282; fax 1-888-656-6671).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

GatewayPAonline prior authorization portal

1-833-895-8282phone contact for Prime Therapeutics Management

1-888-656-6671fax number for prior authorization

Medicare Advantage & Commercialproducts governed

Prior Authorization Coverage Criteria

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General Prior Authorization Criteria

Prior authorization is required for drugs listed in the Coding section when billed to BCBSRI Medicare Advantage and Commercial medical plans, subject to plan benefits and member contract terms.

General requirements: 1) Drug is listed in the policy Coding section as requiring prior authorization; 2) Request submitted to BCBSRI Drug Management vendor via the GatewayPA portal (https://www.GatewayPA.com) for pre-service requests or by contacting Prime Therapeutics Management (phone 1-833-895-8282; fax 1-888-656-6671) to open a retroactive request; 3) Benefits and coverage vary by contract—refer to the Evidence of Coverage or Subscriber Agreement; 4) Authorization requirement does not apply to services rendered in an emergency room, observation, or inpatient setting.

The requirement for prior authorization does not apply when the drug is administered as part of care in an emergency room, observation, or inpatient setting.

Drugs and Coding / Submission Details

Drugs Requiring Prior Authorization (see vendor list)mixed

No codes listed

Submission instructionsCPT|HCPCS|NDC

unlisted code	For drugs with an unlisted code only, the claim must be filed with unlisted code and the NDC.
administration CPT code	If the drug is obtained from Walgreens Specialty Pharmacy, submit the claim with the appropriate administration CPT code, not the drug HCPCS code.

NCD/LCD dosing rule

Applicability for Medicare AdvantageNCD/LCD clinical criteria are used for Medicare Advantage plans, except dosing follows Prime Therapeutics Management policies.

Unlisted codesUnlisted codes follow product labeling (dosing) per policy note.

Claims with unlisted codesWhen a drug has an unlisted code only, file the claim with the unlisted code and the NDC.

Specialty pharmacy submission noteIf obtained from Walgreens Specialty Pharmacy, submit claim with the appropriate administration CPT code instead of the drug HCPCS code.

Provider Submission & Billing Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for the drugs listed in the Coding section below. Use the Drug Management vendor's online portal, GatewayPA, to submit pre-service requests: https://www.GatewayPA.com. Providers may also fax prior authorization forms to 1-888-656-6671. For retroactive requests or assistance, contact Prime Therapeutics Management at 1-833-895-8282. Note: the GatewayPA portal is for contracted providers only; non-contracted providers should call or fax their requests. This prior authorization requirement does not apply to services rendered in an emergency room, observation, or inpatient setting.

Submit requests via GatewayPA: https://www.GatewayPA.com
Fax prior authorization form to 1-888-656-6671
For retroactive requests or questions call Prime Therapeutics Management: 1-833-895-8282
Portal is for contracted providers only — non-contracted providers must call or fax
Authorization requirement excludes ER, observation, and inpatient services

Step Therapy

Step / Coverage Guidance

Step/coverage guidance and coding notes for Medicare Advantage and Commercial products: For Medicare Advantage plans, NCD/LCD criteria are followed for medical necessity determinations; however, dosing guidance follows Prime Therapeutics Management (the Drug Management vendor) policies. Products with only an unlisted code should be billed using the unlisted code plus the product NDC. If a drug is sourced from Walgreens Specialty Pharmacy, submit the claim with the appropriate administration CPT code rather than the drug HCPCS code. Contact Prime Therapeutics Management for policy details at 1-833-895-8282.

Medicare Advantage uses NCD/LCD for coverage criteria; dosing follows Prime Therapeutics Management policies
Unlisted-code-only drugs: file claim with unlisted code and NDC
If obtained from Walgreens Specialty Pharmacy: bill using administration CPT code, not drug HCPCS code
Contact Prime Therapeutics Management: 1-833-895-8282

Billing Rule

Claim Submission Notes

Billing and claim submission notes: when a drug has only an unlisted HCPCS code, include the NDC on the claim. Specialty pharmacy sourcing may change billing expectations (see Walgreens Specialty Pharmacy note above). Ensure administration CPT codes are used where required and follow Prime Therapeutics Management instructions for coding and submission.

For unlisted-code-only drugs, submit claim with the unlisted code and the NDC
If drug is from Walgreens Specialty Pharmacy, submit the administration CPT code (do not submit the drug HCPCS code)
Follow Prime Therapeutics Management billing guidance and coding policies

Denial Risk

Denial Risk if Prior Authorization Not Obtained

Denied claims or services may result if prior authorization is not obtained when required. Providers must obtain prior authorization before rendering non-emergent outpatient drugs identified in the Coding section below to avoid denial or retrospective denials.

Prior authorization required for drugs listed in the Coding section — failure to obtain may result in claim denial
Authorization requirement does not apply to ER, observation, or inpatient settings

Background

This policy defines administrative prior authorization requirements for medical-administered and specialty drugs billed to BCBSRI Medicare Advantage and Commercial medical plans. Clinical guidelines and medical necessity criteria used to review prior authorization requests are maintained by the BCBSRI Drug Management Program vendor and are available on the vendor website. Providers must submit pre-service prior authorization requests via the vendor's online portal at https://www.GatewayPA.com. For retroactive requests or for providers who are not contracted with the portal, contact Prime Therapeutics Management by phone at 1-833-895-8282 or fax prior authorization requests to 1-888-656-6671.

OpenPayer

Prior Authorization of Drugs

Prior Authorization Coverage Criteria

Drugs and Coding / Submission Details

Provider Submission & Billing Actions

Settings Where Authorization Does Not Apply

Key Definitions

Background