Medical Pharmacy Implementation Prior Authorization Program

Blue Cross and Blue Shield of Nebraska (BCBSNE) is committed to providing members with access to high-quality health care consistent with evidence-based, nationally recognized clinical criteria and guidelines. To ensure value to our members, we’re implementing a change in the way we manage certain specialty medications that fall under the medical benefit. This new program will be administered by the Medical Pharmacy Solutions team at Prime Therapeutics Management (Prime).  

Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association. 

Providers and their staff will have the opportunity to obtain prior authorizations to help streamline medication administration and service.  

  • If a prior authorization request does not initially have sufficient evidence to be approved, it is pended to be clinically reviewed by a Prime clinical pharmacist.  
  • If the initial clinical reviewer finds the request meets clinical criteria, the initial clinical reviewer can approve the prior authorization request. 
  • If the initial clinical reviewer cannot find sufficient evidence to approve the request, they will schedule a peer-to-peer conversation between the provider and a Prime peer clinical reviewer, who is a board-certified physician. The Prime peer clinical reviewer will render the final determination based on the information received.  

Note: Prime initial clinical reviewers are clinical pharmacists. 

Please refer to the MA Medical Pharmacy Prior Authorization Program FAQ for additional information.