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
- Solodyn
Androgens/Anabolic Steroids
- Anadrol-50
- Androderm
- Androgel
- Android
- Androxy
- danazol
- First-Testosterone
- Methitest
- Oxandrin
- Striant
- Testim
- Testred
Antifungal Agents
- Lamisil
- Noxafil
- Penlac
- Sporanox
- Vfend
Attention Deficit Hyperactivity Disorder (adult)
- Adderall
- Adderall XR
- Concerta
- Daytrana
- Desoxyn
- Dexedrine
- Dextrostat
- Focalin
- Focalin XR
- Intuniv
- Liquadd
- Metadate CD
- Metadate ER
- Methylin
- Ritalin
- Ritalin LA
- Ritalin SR
- Strattera
- Vyvanse
Enzyme Deficiencies
- Kuvan
Erectile Dysfunction Agents
- Caverject
- Cialis
- Edex
- Levitra
- Muse
- Viagra
Growth Hormones
- Genotropin
- Humatrope
- Norditropin
- Nutropin
- Nutropin AQ
- Omnitrope
- Saizen
- Serostim
- Tev-Tropin
- Zorbtive
Hepatitis C
- Infergen
- Pegasys
- PegIntron
Narcolepsy
- Nuvigil
- Provigil
- Xyrem
Oral Fentanyl
- Actiq
- Fentora
- Onsolis
Retinoids
- Atralin
- Avita
- Retin-A
- Retin-A Micro
- Tazorac
- Tretin-X
- Ziana
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.
Anticonvulsants (epilepsy)
- Keppra
- Keppra XR
- Lamictal
- Lamictal ODT
- Lamictal XR
- Lyrica
- Topamax
- Trileptal
- Vimpat
Antidepressants (depression)
- Aplenzin
- Celexa
- Cymbalta
- Effexor
- Effexor XR
- Lexapro
- Luvox CR
- Paxil
- Paxil CR
- Pexeva
- Pristiq
- Prozac
- Remeron
- Remeron SolTab
- venlafaxine XR
- Wellbutrin
- Wellbutrin SR
- Wellbutrin XL
- Zoloft
Cholesterol
- Advicor
- Altoprev
- Crestor
- Lescol
- Lescol XL
- Lipitor
- Mevacor
- Pravachol
- Simcor
- Vytorin
- Zetia
- Zocor
COX-2 Inhibitor (pain relief)
- Celebrex
Diabetes
- Byetta
- Victoza
Glucose Test Strips
- All non-formulary brand test strips (formulary brands are Abbott and Roche brands, including Accu-Chek, Freestyle and Precision)
Hypertension (high blood pressure)
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Insomnia
- Ambien
- Ambien CR
- Edluar
- Lunesta
- Rozerem
- Sonata
- Zolpimist
Migraine (triptans)
- Amerge
- Axert
- Frova
- Imitrex
- Maxalt
- Maxalt-MLT
- Relpax
- Sumavel DosePro
- Treximet
- Zomig
- Zomig-ZMT
Non-sedating Antihistamines
- Allegra
- Clarinex
- Clarinex D 12 Hour
- Clarinex D 24 Hour
- Semprex D
- Xyzal
Osteoporosis
- Actonel
- Actonel with calcium
- Boniva
- Fosamax
- Fosamax plus D
Proton Pump Inhibitors (control acid production in the stomach)
- AcipHex
- Dexilant (Kapidex)
- Nexium
- pantoprazole
- Prevacid
- Prilosec
- Protonix
- Zegerid
Rheumatoid Arthritis/Psoriasis
- Cimzia prefilled syringe
- Enbrel
- Humira
- Kineret
- Simponi
More information is available in the Prior Authorization Program Member Brochure 
and Step Therapy Program Member Brochure .
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.
