Prior Authorization of Drugs, Effective 5/1/2026 Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 05|01|2026 POLICY LAST REVIEWED: 02|04|2026

OVERVIEW This policy documents drugs that are covered under the member’s Medicare Advantage Plans and Commercial medical plan, which require prior authorization. Prior authorization requests will be handled by BCBSRI’s Drug Management vendor.

MEDICAL CRITERIA Medicare Advantage Plans and Commercial Products Clinical guidelines for approval of medical necessity through prior authorization for the drugs listed in the Coding section below are found on the Drug Management Program vendor's website. Use the following web address for online requests https://www.GatewayPA.com or the prior authorization form can be faxed to 1- 888-656-6671.

PRIOR AUTHORIZATION Medicare Advantage Plans and Commercial Products Prior authorization is required for drugs identified in the Coding section below, Drugs Requiring Prior Authorization.

GatewayPA: https://www.GatewayPA.com, should be used to submit non-urgent/pre-service requests. Expedited/Urgent requests will not be able to be submitted via GatewayPA. Contact Prime Therapeutics Management at 1-833-895-8282 or fax request to 1-888-656-6671 to open an expedited/urgent or retroactive request.

POLICY STATEMENT Medicare Advantage Plans and Commercial Products Prior authorization through the BCBSRI’s Medical Drug Management vendor applies to all drugs that are listed in this policy in the Coding section below, Drugs Requiring Prior Authorization.

NOTE: This authorization requirement does not apply to services rendered in an emergency room, observation or inpatient setting.

As of 5/1/2026, expedited requests for prior authorization must be phoned or faxed.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable physician administered drug benefits/coverage.

Specialty Drug Coverage For contracts with specialty drug coverage, please refer to the member agreement for benefits and prior authorization guidelines.

CODING Medicare Advantage Plans and Commercial Products The following codes require prior authorization.

DRAFT Medical Coverage Policy | Prior Authorization of Drugs

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Drugs Requiring Prior Authorization Note: The ‘Drugs Requiring Prior Authorization’ Excel Document containing the drug codes that require prior authorization will be posted and available on 5/1/2026.

Please note the following:
• For Medicare Advantage Plans, NCD/LCD criteria are used except for dosing, for which Prime Therapeutics Management policies are used. Unlisted codes follow product labeling.
• For drugs with an unlisted code only, the claim must be filed with unlisted code and the NDC. • If the drug is obtained from Walgreens Specialty Pharmacy, please submit the claim with the appropriate administration CPT code, and not the drug HCPCS code.

Contact BCBSRI’s Drug Management vendor, Prime Therapeutics Management at 1-833-895-8282.

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PUBLISHED Provider Update, March 2026 Provider Update, June 2025 Provider Update, March 2024, May 2024, June 2024 Provider Update, February 2023, March 2023, December 2023 Provider Update, May 2022, October 2022, November 2022, December 2022

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS