Prior Authorization and Step Therapy Programs
Prior authorization (PA) and step therapy (ST) encourage safe, cost-effective medication use by allowing coverage when certain conditions are met. A team of physicians and pharmacists develops and approves the clinical programs and criteria for medications that are appropriate for PA and ST by reviewing FDA-approved labeling, scientific literature and nationally recognized guidelines. Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of PA and ST preauthorization requests from physicians for BCBSIL members with prescription drug coverage.
Physicians must complete and submit a preauthorization request form for all medications in the program. Benefits will continue to be available for medications if warranted by the patient’s medical history and current medical condition. The final decision regarding what medications should be prescribed, regardless of benefit determination, is a decision between the patient and their physician. The links below will take you to the Prime Therapeutics website where you may access the PA and ST preauthorization request physician fax forms.
If a member attempts to fill a prescription for a medication included in the PA/ST program, and the program criteria have not been met, the claim will reject. The pharmacy will receive a message stating that PA or ST is required, including a phone number for the pharmacy to contact for further information. The member may still choose to purchase the medication, but will be responsible for the full cost, as coverage will not be available unless PA has been obtained or the applicable ST criteria have been met.
Not all prescription drug benefit plans include the PA/ST program, and the drug categories may vary depending on the member’s plan. To determine if any specific benefit plan includes prior authorization or step therapy, and which drug categories are included, please refer to the member's benefit booklet or call the Pharmacy Program number on the back of the member's ID card.
For more information, review the prior authorization/step therapy program list or call 800-285-9426.
Prime Therapeutics LLC is a pharmacy benefit management company. Blue Cross and Blue Shield of Illinois (BCBSIL) contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC.