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CommercialPrior AuthHigh impact

Medical drug review

Blue Cross Blue Shield of Rhode Island·RI · Oncology, Hematology·Physician / Facility
Effective date
Dec 1, 2019
We identified it
Jun 20, 2026
Days to comply

Summary

BCBSRI is requiring prior authorization for an expanded list of specialty drugs covered under medical benefits for commercial products only, effective December 1, 2019. Prior authorization will be handled by Prime Therapeutics, LLC and does not apply to Medicare Advantage products.

Action Required

Action needed
By December 1, 2019: Billing team must obtain prior authorization from Prime Therapeutics, LLC before administering any of the 22 specialty drugs listed (J-codes J9261, J9032, J9229, J9039, J9044, J9145, J9176, J9307, J9179, J9325, J9315, J9043, J9285, J9203, J9205, J9295, J9262, J9999, J9041, J9153, J9353, A9543) for commercial plan patients. Update billing system to flag these codes for prior auth verification. This requirement does not apply to Medicare Advantage patients.

Affected Billing Codes

J9261
J9032
J9229
J9039
J9044
J9145
J9176
J9307
J9179
J9325
J9315
J9043
J9285
J9203
J9205
J9295
J9262
J9999
J9041
J9153
J9353
A9543