We are live: New Medical Pharmacy Prior Authorization Process for Commercial Plans

On Dec. 9, 2024, we went live with our new Medical Pharmacy prior authorization process with the Medical Pharmacy Solutions team at Prime Therapeutics Management (Prime). Providers are now required to use the Prime GatewayPA when submitting medical pharmacy drugs requiring prior authorization for Commercial members.

With the new process change, we are seeing an increase of prior authorizations being sent that do not require prior approval. Refer to our Medical Pharmacy Policy Updates and Requirements section of our provider website for an update on which products no longer require prior authorization.

The following drugs no longer require prior authorization and will be reviewed post service using post service claim edit policies: Aralast NP, Asparlas, Beleodaq, Besponsa, Botox, Brineura, Daxxify, Dysport, Empliciti, Flolan, Fulphila, Glassia, Myobloc, Neulasta, Prolastin-C, Remodulin, Supprelin LA, Triptodur, Veletri, Xeomin, Xiaflex and Zemaira.

*Note: This list may be subject to change, providers should reference https://www.gatewaypa.com/policydisplay/52 for additional information.

For determination of medical pharmacy drugs requiring prior authorization or post service claim review follow the steps below:

  1. Search In Network Prior Authorization (Provider) | BCBSND
  2. Fill out required fields and submit 
    • National Provider ID
    • Member
    • Date of service 
    • Procedure Code or Service Description
  3. Submit  
    • If the service requires authorization or post-service claim review, follow the instructions listed under the Additional Procedure information section
    • Shown below is a medical pharmacy drug requiring prior authorization or post service claim review.
Medical Pharmacy Prior Authorization
  1. Access https://www.gatewaypa.com/policydisplay/52 to review prior authorization and post service claim edit policies
  2. Access https://www.gatewaypa.com/ to submit a prior authorization request
    1. Providers will have to be registered with the Prime GatewayPA portal
      1. See below for registration assistance
  3. Sign-in
    1. Begin entering in your prior authorization request

How to register
Providers directly contracted with BCBSND may request access to the Prime provider portal.

To do so, visit Prime’s provider portal at www.gatewaypa.com and complete the following steps:

  • Click on New Provider Access Request under the sign in box.
  • Complete the form and click “Register.”

Please have the following information ready:

  • Requestor’s name, email address and phone number
  • Health plan name
  • Provider, facility or group name
  • Provider, facility or group service address
  • Tax ID number
  • NPI

Practice Administrator name and email address (if not the requestor)

* Please allow up to two business days for a response by email.

Claim Adjustments

Medical pharmacy related claims adjustments will be held as BCBSND continues to work through operationalizing the new process. A notification will be sent when claims adjustments will be live.

Resources and References Questions?

Providers can find additional information through the following links:

Additional Questions?
Contact our BCBSND Provider Service Center at 1-800-368-2312.

Note: This new process does not apply to our Medicaid Expansion or Medicare Advantage plans. This new process will not change the retail pharmacy's prior authorization process through the pharmacy benefit.