As prescription drug costs continue to rise, employers, health plans and health care professionals are working together to find ways to manage medication use.

The HMO prior authorization (PA) and step therapy (ST) programs encourage the safe and cost-effective use of medication by allowing coverage when certain conditions are met. Blue Cross and Blue Shield of Illinois (BCBSIL) relies on a clinical team of physicians and pharmacists to identify, develop and approve the clinical programs and criteria for medications that are appropriate for prior authorization. The clinical team reviews FDA-approved labeling, scientific literature and nationally recognized guidelines.

The HMO PA and ST programs include management of the following medications:

Anabolic Steroids

• Anadrol
• Oxandrin
• Winstrol

Growth Hormones

• Genotropin
• Humatrope
• Norditropin
• Nutropin/AQ
• Saizen
• Serostim

Hepatitis C

• Copegus
• Pegasys
• Peg-Intron
• Rebetol
• Ribasphere
• Ribavirin

Hypertension

ACE Inhibitors

• Aceon
• Accupril
• Accuretic
• Altace
• Capoten
• Capozide
• Lotensin/HCT
• Mavik
• Monopril/HCT
• Prinivil
• Prinzide
• Uniretic
• Univasc
• Vaseretic
• Vasotec
• Zestoretic
• Zestril

ARBs

• Atacand/HCT
• Avalide
• Avapro
• Benicar/HCT
• Cozaar
• Diovan/HCT
• Hyzaar
• Micardis/HCT
• Teveten/HCT

Insomnia Step Therapy:

• Ambien
• Ambien CR
• Lunesta
• Sonata
• Rozerem

Oral Fentanyl Prior Authorization:

• Actiq
• Fentanyl lollipop
• Fentora

Rheumatoid Arthritis/Psoriasis

• Amevive
• Enbrel
• Humira
• Kineret
• Raptiva

When a member fills or refills a prescription for one of the medications listed above, the prescription claim will reject, and the pharmacy will receive a message stating that prior authorization is necessary. It will then be necessary for the physician to complete and submit a BCBSIL preauthorization request physician fax form. Continued use will be available if the patient's medical history and current medical condition warrant it.

For information about the prior authorization medical criteria for anabolic steroids and growth hormones, please review medical policies or the Rx clinical criteria.

If you have questions or concerns regarding these programs, please call the Pharmacy Program at (800) 423-1973.

Preauthorization Request Physician Fax Forms

ACE/ARB
Anabolic Steroid
Growth Hormone
Insomnia Agents
Leukotriene Modifiers (Accolate^®, Singulair^®, Zyflo^®, Zyflo CR)
Oral Fentanyl
Peginterferon (Hepatitis C)
Rheumatoid Arthritis/Psoriasis (Enbrel^®, Humira^®, Kineret^®, Amevive^®, Raptiva^®)

HMO Prior Authorization and Step Therapy Program Brochures 

Prior Authorization Program Member Brochure
Step Therapy Program Member Brochure