Medicare Advantage (MA) Part B Drug Prior Authorization List

This procedure outlines the codes that fall under the Medicare Advantage Part B Drug prior authorizations.

We contract with MagellanRX for Part B drugs/medications.  
Please submit PA request directly to MagellanRX.

• Hours of Operation: 24 hours a day 
• Call toll free: 1-800-424-1709 or fax 1-888-656-6671
• Website: MRxGateway.com

We contract with Prime for Part D drugs/medications.  
Please submit PA request directly to Prime Therapeutics

• Hours of Operation:  24 hours a day, 7 days a week, 365 days a year
• Call 1-855-457-1349 or fax 1-855-212-8110
• Website:  MyPrime.com 

Please note: Per CMS, expedited requests should ONLY be requested when the health care provider believes that waiting for a decision under the standard review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function. Please be mindful of this definition when submitting your requests so that we can prioritize and process all requests appropriately.

Blue Cross and Blue Sheild of Nebraska (BCBSNE) follows CMS coverage guidance when reviewing codes when available. CMS coverage documents, including National Coverage Determinations and Local Coverage Determinations, can be found by using the CMS Medicare Coverage Database search tool. BCBSNE also uses Interqual^® clinical criteria and medical policies. For more information, please review the BCBSNE MA Provider Procedures searchable tool on NebraskaBlue.com/Providers/BCBSNE-Provider-Procedures.

Below are the links for the provider polices that these codes fall under.

Add link for Step Therapy Policy # M.18

LCD/NCD Policy # M.17

No LCD/NCD Policy # M.16

Prior authorization is not a guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable contract terms.