Non-HMO Fully Insured Groups: Prior Authorization/Step Therapy Program
Blue Cross and Blue Shield of Illinois' (BCBSIL) prior authorization/step therapy program is designed to encourage safe, cost-effective medication use. Most fully insured groups include this program.
Prior Authorization
Under this part of the program, the member’s physician will be required to obtain authorization from BCBSIL in order for the member to receive benefits for certain medications and drug categories. If a prior authoziation request is not approved, the member can still obtain the medication, but will be responsible for the first $1,000, or 50 percent of the Eligible Charge (as explained in more detail in the benefit booklet), whichever is less.
Below are drug categories and specific medications* for which a prior authorization program exists for most fully insured group members. Please note that the drug categories and medications may change from time-to-time. For the most up-to-date list, members should call the Pharmacy Program number on the back of their BCBSIL ID card.
As always, cost is only one factor in choosing medication, and treatment decisions are between the member and physician.
Androgens/Anabolic Steroids
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Antifungal Agents
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Doxycycline/Minocycline
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Erectile Dysfunction Agents
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Narcolepsy
- Nuvigil
- Provigil
- Xyrem
Oral Fentanyl
- Abstral
- Actiq
- Fentora
- Onsolis
Specialty Prior Authorization
Cryopyrin-Associated Periodic Syndromes (CAPS)
- Arcalyst
Enzyme Deficiency
- Kuvan
Erythropoiesis Stimulating Agents (ESA)
- Aranesp
- Epogen
- Procrit
Growth Hormones
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Hepatitis C
- Infergen
- Pegasys
- PegIntron
Huntington's Chorea
- Xenazine
Idiopathic Thrombocytopenic Purpura (ITP)
- Promacta
Multiple Sclerosis
- Ampyra
Osteoporosis
- Forteo
Pulmonary Arterial Hypertension (PAH)
- Adcirca
- Revatio
Step Therapy
Step therapy is a type of prior authorization. In order for a member to receive coverage for drugs included in this part of the program, the physician will be required to obtain authorization from BCBSIL.
As an alternative to asking their doctor to receive prior authorization, or paying the entire cost of the medication out-of-pocket, members, along with their physician, may decide that a lower-cost generic or brand alternative medication that is not part of the program is an appropriate option. The plan will provide benefits for medications included in the program when the member first tries a lower-cost medication or the doctor obtains prior authorization of coverage through BCBSIL.
Below are drug categories and specific medications* for which a step therapy program exists for most fully insured group members. Step therapy does not apply to the generic equivalents for these medications (if available). If the member and physician decide the generic equivalent is an appropriate option, the member will not need to go through the prior authorization process. Please note: 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 the drug categories and medications may change from time-to-time. For the most up-to-date list, members should call the Pharmacy Program number on the back of their BCBSIL ID card.
As always, cost is only one factor in choosing medication, and treatment decisions are between the member and doctor.
Cholesterol
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Depression (Antidepressants)
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Diabetes (Glucagon-like Peptide-1 Receptor Agonists)
- Byetta
- Victoza
Gastroesophageal Reflux Disease (Proton Pump Inhibitors)
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Glucose Test Strips
- All non-formulary brand test strips and disks (formulary brands are Bayer (as of 4/1/11) and Roche)
Hypertension (High Blood Pressure)
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Insomnia
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Migraine (Triptans)
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Non-Sedating Antihistamines
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Osteoporosis (Bisphosphonates)
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Pain Management
- Celebrex
- Vimovo
Specialty Step Therapy
Infertility
- Gonal F
Multiple Sclerosis
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Pulmonary Arterial Hypertension
- Letairis
Rheumatoid Arthritis/Psoriasis (Biologic Immunomodulators)
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More information is available in the Prior Authorization Program Member Flier 
and Step Therapy Program Member Flier .
Members should call the Pharmacy Program number on the back of their BCBSIL ID card with questions about the prior authorization/step therapy program.
* Third-party brand names are the property of their respective owners.
