Specialty Pharmacy

Prime Therapeutics Management is the Medical Specialty Pharmacy division of Prime Therapeutics.

The program will apply to members enrolled in the following plans:

• Federal Employee Program Standard
• Federal Employee Program Basic
• Federal Employee Program Blue Focus

The effective date of this program is March 1, 2022.

Prime Therapeutics PA Drug List

The list of medications included in the Medical Pharmacy Program is updated at least annually.

View Clinical Policies & Guidelines at CVS/Caremark and/or FEP.

Prior authorizations are required for medications administered at the following places of service:

• Physician office (CMS Place of Service code 11)
• Patient’s homes (CMS Place of Service code 12)
• Outpatient facilities (CMS Places of Service codes 19 & 22)
  

Providers may call Prime Therapeutics for authorization requests at 800-443-5709. 

If the provider is contracted directly with Arkansas Blue Cross and Blue Shield, non-urgent authorizations also may be done through the secure Prime Therapeutics secure provider portal at www.gatewaypa.com.

To expedite prior authorizations, the provider should have the following information:

• Member name, date of birth and ID number
• Health plan name (Arkansas Blue Cross and Blue Shield)
• Member height and weight
• Ordering provider name, tax ID number, address, and office telephone and fax numbers
• Rendering provider name, tax ID number, address, and office telephone and fax numbers (if different from ordering provider)
• Requested medication name or Healthcare Common Procedure Coding System (HCPCS) code
• Anticipated start date of treatment
• Dosing information and frequency
• Diagnosis (ICD-10 code)
• Any additional clinical information pertinent to the request

If requested by Prime Therapeutics, the provider should be prepared to upload the following documents to the Prime Therapeutics provider portal or to fax the following documents to Prime Therapeutics Health Insurance Portability and Accountability Act (HIPAA)-compliant fax:

• Clinical notes
• Pathology reports
• Relevant lab test results

Note: It is the responsibility of the ordering provider to obtain prior authorization before services are provided. If the ordering provider and the rendering provider are different, the rendering provider is responsible for ensuring that the appropriate approval is on file, prior to rendering services.

Providers directly contracted with Arkansas Blue Cross and Blue Shield may request access to the Prime Therapeutics provider portal. To do so, visit Prime Therapeutics provider portal at www.gatewaypa.com and complete the following steps:

• Click on New Provider Access Request at the bottom of the page.
• Complete the form and allow two business days for response.

Please have the following information ready:

• Requestor’s name, email address, and phone number
• Practice administrator name and email address (if different from requestor)
• Health plan name (Arkansas Blue Cross and Blue Shield)
• Practice name
• Practice service address
• Practice National Provider Identifier (NPI)
• Practice tax ID number

Please email the Prime Medical Pharmacy Solutions Provider Relations team at [email protected] with any questions.

No. Prime Therapeutics provider portal users linked to the practice tax ID number will be able to conduct transactions for every network clinician linked to the practice tax ID number.

Prime Therapeutics has been engaged only to oversee utilization management. Claims should be submitted to Arkansas Blue Cross and Blue Shield.

Yes. The claim for the rendering provider will be denied. Rendering providers need to make sure a prior authorization is on file with Prime Therapeutics before administering the medications to members. When prior authorization is required but was not obtained, providers can follow instructions on the Explanation of Benefits (EOB) to submit a claim appeal, as applicable.

For more information, providers can call Prime Therapeutics at 800-443-5709.

Yes. In most cases, approvals can be made based on the initial information provided by the requestor. If there is a question or concern regarding the information provided, the case will be sent to a pharmacist who will reach out to the requesting provider. If the pharmacist cannot reach an agreement regarding the appropriate course of treatment with respect to the requested medication, the case will be escalated to a Prime Therapeutics physician. A Prime Therapeutics physician will discuss the case with the provider, and they will make a mutual decision, in accordance with plan guidelines, on an appropriate course of action.

The ordering provider, rendering provider (if different from ordering) and member receive copies of the final determination notices.

Prime Therapeutics approvals link providers by their tax ID number. When approvals are entered into Arkansas Blue Cross and Blue Shield cross claims system, they will be attached to all network providers who share that tax ID number.

Providers who are directly contracted with Arkansas Blue Cross and Blue Shield must be signed into their account page on the Prime Therapeutics provider portal at www.gatewaypa.com.

• After entering your patient’s information and selecting yourself or your group’s name as the requesting provider, answer yes to the question “Will an alternative servicing provider be utilized for this request?”
• Search for and select the outpatient facility site where the member will receive the treatment.
• Continue entering the prior authorization request.

If the request is made by phone, the requestor should provide this information to the Prime Therapeutics team.

All rendering providers are required to check the Prime Therapeutics provider portal to confirm a prior authorization has been issued prior to administering a medication that is part of this program.

The outpatient facility will receive a copy of the approval letter and can view the status of the approval via Prime Therapeutics provider portal www.gatewaypa.com.

To view a prior authorization, providers directly contracted with Arkansas Blue Cross and Blue Shield must be signed into their Prime Therapeutics provider portal account at www.gatewaypa.com:

• Select View Prior Authorizations and enter either the patient’s first and last name, the member identification number, or the authorization number. Providers also have the option of viewing all prior authorizations associated with their tax ID number.
• The provider should confirm the following information on the prior authorization:
  • Member name, date of birth, and ID number
  • Ordering and rendering provider information
  • Authorization validity period
  • The medication(s) and number of units approved

If a provider has any questions, he/she should contact Prime Therapeutics directly at 800-443-5709.

After an approval is generated, a change in dose and/or frequency may be requested via phone by Prime Therapeutics at 800-443-5709.

The approval duration or validity period of a prior authorization is dependent on the medication and is not negotiable.  

There is one prior authorization number per medication. However, Prime Therapeutics can process multiple requests via a single portal session or telephonic request.