Administrative bulletin: 2026-01-002 Reminders

Date: January 1, 2026

Topics covered in this Administrative Bulletin are applicable to:

Professional and Facility Providers

Unless otherwise noted, if you have any questions regarding the information in this bulletin, please contact your Provider Engagement Consultant or use our Provider engagement consultant look up tool and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.

Professional and facility Providers

Prime Therapeutics (Prime) Medical Drug Management - Specialty Injectable Medications

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Effective January 1, 2026, Prime Therapeutics (Prime) will manage preauthorization for specialty medications routinely covered under a patient’s medical benefit. Providers will be required to obtain preauthorization for certain specialty injectables directly through Prime via www.GatewayPa.com.

Capital Blue Cross remains committed to the delivery of quality and affordable care to our members, consistent with evidence-based, nationally recognized clinical care and criteria. Therefore, beginning January 1, 2026, Prime’s Medical Pharmacy Solutions team will manage our specialty injectable medications program.

Certain medical injectable medications require preauthorization to be eligible for coverage under the medical benefit. These medications are maintained on the Capital Blue Cross Single Source Preauthorization List located on Capital’s provider web page, and may be updated from time to time.

Requesting a preauthorization:

For dates of service on or after January 1, 2026, Providers will be required to obtain preauthorization through Prime via www.GatewayPa.com for specialty injectable medications administered in the following settings: Physician office (POS 11), Patient Home (POS 12), or Outpatient Facilities (POS 19, 22).

Viewing/Accessing a preauthorization:

A rendering facility or physician can view authorizations in two ways:

  1. Creating an account on the Prime portal (GatewayPa.com) – Allows a search by member name and/or service date.
  2. Tracking number – Without an account, the rendering physician/facility would need the preauthorization tracking number from the ordering physician.

Appeals:

Commercial and CHIP – First-level, pre-service medical necessity appeals will be delegated to Prime. Appeal requests must be submitted within:

  • Commercial and CHIP – 180 days after receiving the Notice of Adverse Benefit Determination. Please refer to the notice letter for specific instructions.

Medicare Advantage – First-level medical necessity appeals should be submitted to Capital. Submit appeals in accordance with the normal appeal process guidelines.