Prior Authorization of Drugs
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Defines prior authorization requirements and submission process for drugs under BCBSRI Medicare Advantage and Commercial medical plans; applies to contracted providers submitting pre-service or retroactive requests via the plan's drug management vendor.
No material clinical or coverage changes in this revision.
Coverage and Benefit Applicability
Coverage overview
Covered when ALL of the following apply:
ALL of the following
- The drug is listed in the Coding section (Drugs Requiring Prior Authorization) of this policy and therefore requires prior authorization through BCBSRI's Medical Drug Management vendor.
- The request is for a member whose benefits include physician‑administered drug coverage; benefits may vary by group/contract — refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage determinations.
- For contracts with specialty drug coverage, the member agreement's specialty drug benefits and prior authorization guidelines apply.
- This prior authorization requirement does not apply to services rendered in an emergency room, observation, or inpatient setting.
Operational notes
- Prior authorization requests for drugs listed in the Coding section must be submitted to BCBSRI's Medical Drug Management vendor per the Provider Actions section of this policy; see provider submission instructions for portal, phone, and fax options.
- Benefits and coverage determinations are subject to the individual member's contract; authorization approval does not guarantee payment if the service is not a covered benefit under the member's plan.
Scope
- Applies to BCBSRI Medicare Advantage and Commercial medical plans and to contracted providers submitting pre‑service or retroactive requests via the plan's drug management vendor.
Drugs Requiring Prior Authorization and Claim Coding
| See external spreadsheet | List of drugs requiring prior authorization is provided in linked Excel file for Commercial and Medicare. |
Prior Authorization Submission and Provider Instructions
Submit prior authorization via GatewayPA (pre-service) or contact Prime for retroactive requests
Prior authorization is required for drugs identified in the Coding section; use the GatewayPA portal for online pre-service requests. For retroactive requests, contact Prime Therapeutics Management at 1-833-895-8282 or fax to 1-888-656-6671.
- Online pre-service submissions: https://www.GatewayPA.com
- Retroactive requests: call 1-833-895-8282 or fax 1-888-656-6671
Portal access limited to contracted providers; others must call or fax
The GatewayPA portal is intended for contracted providers only. Non-contracted providers must call Prime Therapeutics Management or fax requests to open prior authorizations.
- Portal use: contracted providers only
- Non-contracted providers: call 1-833-895-8282 or fax 1-888-656-6671 to submit requests
No prior authorization required for ER, observation, or inpatient care
The prior authorization requirement does not apply to services provided in the emergency room, observation, or inpatient settings.
- Do not obtain prior authorization for drugs administered in ER, observation, or inpatient encounters
Key Definitions
Site of Care Applicability
Hospital outpatient / site-of-care PA exemption
Authorization requirements do not apply to services provided in the emergency room, observation, or inpatient settings; hospital outpatient services in these contexts are exempt from PA.
- PA exemption covers ER, observation, and inpatient settings for hospital outpatient care.
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