Self-Funded Groups: Prior Authorization/Step Therapy Program
The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use.
Blue Cross and Blue Shield of Illinois (BCBSIL) offers self-insured groups a variety of prior authorization and step therapy programs to help effectively manage their prescription drug benefit.
Prior Authorization
Under this part of the program, the physician will be required to obtain authorization from BCBSIL in order for the member to receive benefits for certain medications and drug categories.
The following prior authorization programs, listed along with sample medications*, are currently available to self-insured groups.
Acne Topical
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Androgens/Anabolic Steroids
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Antifungal Agents
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Attention Deficit Hyperactivity Disorder (Adults)
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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 members 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 physician obtains prior authorization of coverage through BCBSIL.
The following step therapy programs, listed along with sample medications*, are currently available to self-insured groups. 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.
Cholesterol
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Depression (Antidepressants)
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Diabetes (Glucagon-like Peptide-1 Receptor Agonists)
- Byetta
- Victoza
Epilepsy (Anticonvulsants)
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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
- Betaseron
- Extavia
- Gilenya
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 .
As always, cost is only one factor in choosing medication, and treatment decisions are between members and their physician.
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.
