Prior authorization request form 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 UPDATED: 05|01|2026

OVERVIEW BCBSRI is implementing a change in the way we manage certain drugs that fall under the medical and specialty benefit. This policy is a tool for providers to use to manage medications that will be subject to post service claims editing.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Prior Authorization is not required

POLICY STATEMENT Medicare Advantage Plans and Commercial Products Effective May 1, 2026, the following listed medications will be subject to post service claims editing.

Claims will be reviewed by the drug code based on the following criteria: • Diagnosis appropriate for code • Dosing
• Units billed • NDC match

Please note this is not an all-inclusive list

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate member certificate/subscriber agreement for applicable physician services coverage/benefits.

BACKGROUND Blue Cross & Blue Shield of Rhode Island (BCBSRI) is committed to providing our members with access to high-quality health care that is consistent with evidence-based, nationally recognized clinical criteria and guidelines. Therefore, we will be implementing a change in the way we manage certain specialty drugs that fall under the medical benefit. This new program will be administered by the Medical Pharmacy Solutions team at Prime Therapeutics (Prime).

CODING Medicare Advantage Plans and Commercial

Please see drug lists for both Commercial and Medicare Advantage plans that do not require Prior Authorization but will be subject to the post service claims edit. Payment Policy | Pharmacy – Post Claim Review Medications

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

Commercial Drug List Medicare Advantage Drug List

1. RELATED POLICIES Prior Auth drug policy

   PUBLISHED Provider Update, February 2026

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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