Pharmacy Programs for Non-HMO Members

These pharmacy programs are available for non-HMO members.

Over-the-Counter Equivalent Exclusion Program

Medications with an equivalent available over-the-counter (OTC) are usually not covered through Blue Cross and Blue Shield of Illinois prescription drug plans.

Some facts to consider:

  • You will not usually receive coverage for brand and generic prescription medications that have OTC versions available at the same prescription strength.
  • You may still purchase the medication – either by prescription or over-the-counter – but you will be responsible for the full cost of the drug.
  • Choosing to purchase the OTC version will often save you money.
  • To see if a specific drug is part of the program, view the over-the-counter equivalent exclusion program drug list PDF Document
  • If you have questions about the program, call the Pharmacy Program number on the back of your ID card.
  • Talk with your doctor before making any changes to your current medication regimen. As always, treatment decisions are between you and your doctor.

This program does not apply to members who have outpatient prescription drug coverage through their medical plan, processed by BlueSCRIPTSM.

Mail Service Program

PrimeMail®, the mail service pharmacy for members with BCBSIL prescription drug coverage, provides safe, fast and cost-effective pharmacy services that can save you time and money. With this program, you can obtain up to a 90-day supply of long-term (or maintenance) medications through PrimeMail. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes. View the maintenance drug list PDF Document to see if your medication is included.

Ordering Through PrimeMail

When you log in to Blue Access for Members and visit your Rx Drugs page, you can use the online order form, print an order form to mail or ask that PrimeMail get in touch with your doctor to request a new prescription.

For more information about using mail service:

  • Download the PrimeMail flier PDF Document.
  • Call the Pharmacy Program number on the back of your ID card

Specialty Pharmacy Program

Your prescription drug benefit may include a specialty pharmacy program through Prime Therapeutics Specialty Pharmacy (Prime Specialty Pharmacy).

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis. These drugs are typically given by injection, but may be topical or taken by mouth. They often require careful adherence to treatment plans, have special handling or storage requirements, and may not be stocked by retail pharmacies.

View the Specialty Pharmacy Program Drug List PDF Document which includes a reminder about coverage for self-administered specialty medications.

When you purchase specialty medications through Prime Specialty Pharmacy, you can have your self-administered specialty medications delivered directly to you, or to your doctor's office. You also receive at no additional charge:

  • Support services for managing your drug therapy
  • Educational materials about your particular condition
  • Help with managing potential medication side effects
  • 24/7/365 customer service phone access

BCBSIL members who use oral oncology or hemophilia specialty drugs may have other in-network specialty pharmacy options. Log in to your Blue Access for MembersSM account to find a preferred specialty pharmacy near you.


Note: Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Prior Authorization/Step Therapy Program

The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use.

This program may be part of your prescription drug benefit plan. To find out if your specific benefit plan includes the prior authorization/step therapy program, and which drugs are part of your plan, refer to your plan materials, or call the Pharmacy Program number on the back of your ID card.

Prior Authorization

Under this program, your doctor will be required to request pre-approval, or prior authorization, through Blue Cross and Blue Shield of Illinois in order for you to get benefits for select drugs.

  • Examples of drug categories and specific medications for which a prior authorization program may be included as part of your prescription drug benefit plan are listed below.
  • Please note that not all drug categories are included in all benefit plans. Additional drug categories may be added and the medications listed are only examples. Call the Pharmacy Program number on the back of your ID card with questions about a specific medication.
  • If you are taking, or prescribed, a drug that is newly introduced to the market, you may need to have your doctor submit a prior authorization request in order to get benefits for such drugs. If you have questions about your medicine, call the number on the back of your ID card.
  • As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
Drug Category Prescription Drugs within the Category*
Prior Authorization
Addyi Addyi
Afrezza Afrezza
Androgens/Anabolic Steroids Anadrol-50, Androderm, Androgel, Android, Androxy, Aveed, Axiron, danazol, Delatestryl, Depo-Testosterone, First-Testosterone, Fortesta, Methitest, Natesto, Oxandrin, Striant, Testim, Testone CIK, Testopel, Testred, Vogelxo
Antifungal Agents Cresemba, Noxafil, Vfend
Circadian Rhythm Disorders (formerly Hetlioz) Hetlioz
Doxycycline/Minocycline Doxycycline products: Acticlate, Adoxa, Alodox, Avidoxy DK, Doryx (and generic equivalents), Doryx MPC (and generic equivalents), doxycycline, Monodox, Morgidox Kit, Nicazeldoxy, Nutridox Kit, Ocudox Kit, Oracea, Oraxyl, Targadox, Vibramycin
Minocycline products: Dynacin, Minocin, Minocin Kit, Solodyn (and generic equivalents)
Erectile Dysfunction (ED) Caverject, Cialis, Edex, Levitra, Muse, Staxyn, Stendra, Viagra
Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker Corlanor
Insulin Agents Apidra, Humalog, Humalog Mix 75/25, Humalog KwikPen U200, Humalog Mix 50/50, Humulin R U-100, Humulin N, Humulin 70/30
Narcolepsy Nuvigil, Provigil
Xyrem is also included in this program. See separate entry in Specialty Prior Authorization section.
Neprilysin Inhibitor Entresto
Ophthalmic Immunomodulators Restasis, Xiidra
Opioid Dependence Bunavail, Suboxone, Subutex, Zubsolv
Opioid Induced Constipation Movantik, Relistor
Oral Immunotherapy Grastek, Oralair, Ragwitek
Therapeutic Alternatives Absorica, Amrix, Ativan, Bupap, Cambia, Carac/Fluorouracil, Cardizem CD, Cuprimine, Daraprim, Dexpak, Durlaza, Evzio, Fortamet, Glumetza/metformin extended release, Kadian, Kazano, lidocaine ointment, Lidoderm, Nesina, Northera, Onmel, Oseni, Pandel, Primlev, Rayos, Sitavig, Solaraze/generic diclofenac gel, Sporanox, Spritam, Vivlodex, Zegerid, Zyflo/Zyflo CR
Topical Antifungal Agents CNL8, Ciclodan, Jublia, Kerydin, Pedipak, Pedipirox-4 Nail, Penlac
Transmucosal Immediate Release Fentanyl Abstral, Actiq, Fentora, Lazanda, Subsys
Specialty Prior Authorization
Cerdelga Cerdelga
Cystic Fibrosis Kalydeco, Orkambi
Enzyme Deficiency Kuvan
Erythropoiesis Stimulating Agents (ESAs) Aranesp, Epogen, Mircera, Procrit
Growth Hormone/Egrifta Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-tropin, Zomacton, Zorbtive; Egrifta
H.P. Acthar (Pituitary Hormone) H.P. Acthar Gel
Hepatitis B & C Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PegIntron, Sovaldi, Technivie, Viekira PAK, Viekira XR, Zepatier
Huntington's Chorea Xenazine
Hypercholesterolemia Juxtapid, Kynamro, Praluent, Repatha
Idiopathic Pulmonary Fibrosis (IPF) Esbriet, Ofev
Inherited Autoinflammatory Disorders Arcalyst
Korlym Korlym
Multiple Sclerosis Ampyra
Myalept Myalept
Natpara Natpara
Ocaliva Ocaliva
Osteoporosis Forteo
Pulmonary Arterial Hypertension (PAH) Adcirca, Adempas, Letairis, Orenitrum, Opsumit, Revatio, Tracleer, Tyvaso, Uptravi, Ventavis
Self-Administered Oncology Afinitor, Afinitor Disperz, Alecensa, Bosulif, Cabometyx, Caprelsa, Cometriq, Cotellic, Erivedge, Farydak, Gilotrif, Gleevec, Hexalen, Hycamtin, Ibrance, Iclusig, Imbruvica, Inlyta, Iressa, Jakafi, Lenvima, Lonsurf, Lynparza, Lysodren, Matulane, Mekinist, Nexavar, Ninlaro, Odomzo, Pomalyst, Revlimid, Sprycel, Stivarga, Sutent, Sylatron, Tafinlar, Tagrisso, Tarceva, Targretin, Tasigna, Temodar, Thalomid, Tretinoin, Tykerb, Venclexta, Votrient, Xalkori, Xeloda, Xtandi, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga
Short Bowel Syndrome Gattex
Thrombopoietin Receptor Agonists Promacta
Urea Cycle Disorders Buphenyl, Ravicti
Xyrem Xyrem


* Third-party brand names are the property of their respective owners.

More information is available in the prior authorization member flier PDF Document.

Step Therapy

The step therapy program requires that you have a prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug.

  • A first-line drug is recognized as safe and works well in treating a specific medical condition, as well as being a cost-effective treatment option.
  • A second-line drug is a less-preferred or likely a more costly treatment option.

Step 1: If possible, your doctor should prescribe a first-line medication right for your condition.

Step 2: If you and your doctor decide that a first-line drug is not right for you or is not as good in treating your condition, your doctor should submit a prior authorization request for coverage of the other drug.

  • Below are examples of drug categories and specific medications for which a step therapy program may be included as part of your prescription drug benefit plan.
  • Step therapy does not apply to the generic equivalents for these medications (if available), so if you and your doctor decide the generic equivalent is best for you, prior authorization is not required.
  • These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.
  • Please note that not all drug categories are included in all benefit plans. Additional drug categories may be added and the medications listed are only examples. Call the Pharmacy Program number on the back of your ID card with questions about a specific medication.
  • As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
Drug Category Prescription Drugs within the Category*
Step Therapy
Atopic Dermatitis Elidel, Protopic/tacrolimus
Atypical Antipsychotics Abilify, Abilify Discmelt, Abilify Maintena, Aristada, clozapine ODT, Clozaril, Fanapt, FazaClo, Geodon, Invega, Invega Sustenna, Invega Trinza, Latuda, Rexulti, Risperdal, Risperdal M-Tab, Risperdal Consta, Saphris, Seroquel, Seroquel XR, Versacloz, Vraylar, Zyprexa, Zyprexa Zydis, Zyprexa Relprevv
Cox-2/NSAID GI Protectant (Pain Management) Celebrex, Duexis, Vimovo
Depression Aplenzin, Celexa, Cymbalta, Desvenlafaxine ER tabs, Desvenlafaxine fumarate, Duloxetine, Effexor, Effexor XR, Fetzima, fluoxetine 60 mg tabs, Forfivo XL, Irenka, Khedezla, Lexapro, Luvox CR, maprotiline, Oleptro, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Prozac Weekly, Remeron, Remeron SolTab, Trintellix, venlafaxine ER tabs, Viibryd, Viibryd Starter Kit, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zoloft
Diabetes (GLP-1 Receptor Agonists) Bydureon, Byetta, Tanzeum, Trulicity, Victoza
Fibrates Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, Triglide, Trilipix
Glucose Test Strips All non-preferred brand test strips and disks
Lipid Management (Cholesterol) Advicor, Altoprev, Crestor, Lescol, Lescol XL, Lipitor, Liptruzet, Livalo, Mevacor, Pravachol, Simcor, Vytorin, Zocor
Ophthalmic Prostaglandins Lumigan, Rescula, Travatan Z, Travoprost, Xalatan, Zioptan
Topical Non-Steroidal Anti-Inflammatory Drug Flector, Pennsaid, Voltaren
Specialty Step Therapy
Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis) Actemra subcutaneous, Cimzia, Cosentyx, Enbrel, Entyvio, Humira, Humira starter kit, Kineret, Orencia subcutaneous, Otezla, Simponi, Stelara, Taltz, Xeljanz, Xeljanz XR
Infertility Bravelle, Gonal F, Gonal F RFF
Iron Chelator Ferriprox
Multiple Sclerosis Aubagio, Avonex, Extavia, Gilenya, Zinbryta


* Third-party brand names are the property of their respective owners.

More information is available in the step therapy member flier PDF Document.

If you have questions about the prior authorization/step therapy program, call the Pharmacy Program number on the back of your BCBSIL ID card.

Vaccine Program

If you have coverage through Blue Cross and Blue Shield of Illinois, vaccinations may be covered under the medical benefit or prescription drug benefit, based on your plan. Select vaccines can be conveniently administered at a pharmacy near you. These vaccines can help protect you and your covered family members from illnesses such as the flu, pneumonia, shingles, meningitis, HPV, rabies, hepatitis B, tetanus, diphtheria and pertussis.

To see which vaccines are covered under your plan, check your benefit materials for details and any necessary copays. Or, you can call the Pharmacy Program number on the back of your ID card.

  • The select vaccines covered under the prescription drug benefit are conveniently administered at a participating vaccine network pharmacy. Just hand your ID card to the pharmacist.
  • To see a complete list of all participating pharmacies, search the pharmacy network on myprime.com and filter for vaccine pharmacies. Or, you can call the number on the back of your ID card.
  • Before you go, be sure to confirm the location's participation and hours, vaccine availability and ask about any other age limits, restrictions or requirements that may apply.