BCBSIL Pharmacy programs for HMO Members

Over-the-Counter Equivalent Exclusion Program

Medications with an equivalent available over-the-counter (OTC) are usually not covered through Blue Cross and Blue Shield of Illinois (BCBSIL) prescription drug plans.

Some facts to consider:

You will not usually receive coverage for brand and generic prescription medications that have OTC versions available at the same prescription strength.
You may still purchase the medication – either by prescription or over-the-counter – but you will be responsible for the full cost of the drug.
Choosing to purchase the OTC version will often save you money.
To see if a specific drug is part of the program, view the over-the-counter equivalent exclusion program drug list.
If you have questions about the program, call the Pharmacy Program number listed on the back of your BCBSIL member ID card.
Talk with your doctor before making any changes to your current medication regimen. As always, treatment decisions are between you and your doctor.

This program does not apply to members who have outpatient prescription drug coverage through their medical plan, processed by BlueSCRIPT^SM.

90-Day Supply Program

The 90-day supply benefit program can save you both time and money. With this program, you have the option of getting up to a 90-day supply of long-term (or maintenance) medications through a network of contracting extended supply retail and mail service pharmacies. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes.

For more information, download the 90-Day Supply Program Member Flier.

Getting Started

1. Ask your doctor for a prescription of a 90-day supply of each of your long-term medicines.

2. To purchase your prescription:

At a network “90-day” retail pharmacy – take your prescription to your pharmacy or have your doctor submit the prescription electronically.
Through mail order – order online, through a mobile device, over the phone or through the mail. You can find contact information for these pharmacies at myprime.com.

Tips for using mail order:

If you need to start your prescription right away, ask your doctor for a one-month supply you can fill at a retail pharmacy.
If mailing your order, you can find a new prescription order form at myprime.com. Print and fill out the order form. Send the completed order form, your prescription and payment to the mail-order pharmacy.
Keep in mind that medicines can take up to 5 business days to deliver after the pharmacy receives and verifies your order.

Prior Authorization/Step Therapy Program

The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use. This program may be part of your prescription drug benefit plan. To find out if your specific benefit plan includes the prior authorization/step therapy program, and which drugs are part of your plan, refer to your benefit materials.

Prior Authorization

Under this program, your doctor will be required to request pre-approval, or prior authorization, through BCBSIL for you to get benefits for the select drugs.

Examples of drug categories and specific medications for which a prior authorization program may be included as part of your prescription drug benefit plan are listed below.
Please note that not all drug categories are included in all benefit plans. Additional drug categories may be added and the medications listed are only examples. Call the number on the back of your member ID card with questions about a specific medication.
If you are taking, or prescribed, a drug that is newly introduced to the market on or after October 1, 2015, you may need to have your doctor submit a prior authorization request in order to get benefits for such drugs. If you have questions about your medicine, call the number on the back of your member ID card.
As always, cost is only one factor in choosing medication, and treatment decisions are between you and your doctor.

Step Therapy

The step therapy program requires that you have prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug. A first-line drug is recognized as safe and works well in treating a specific medical condition, as well as being a cost-effective treatment option. A second-line drug is a less-preferred or likely a more costly treatment option.

Step 1: If possible, your doctor should prescribe a first-line medication that is right for your condition.

Step 2: If you and your doctor decide that a first-line drug is not right for you or is not as good in treating your condition, your doctor should submit a step therapy exception request for coverage of the other drug.

Below are examples of drug categories and specific medications for which a step therapy program may be included as part of your prescription drug benefit plan.
Step therapy does not apply to the generic equivalents for these medications (if available), so if you and your doctor decide the generic equivalent is best for you, prior authorization is not required.
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 not all drug categories are included in all benefit plans. Additional categories may be added and the medications listed are only examples. Call the number on the back of your member ID card with questions about a specific medication.
As always, cost is only one factor in choosing medication, and treatment decisions are between you and your doctor.

If you have questions about the prior authorization/step therapy program, call the number on the back of your BCBSIL member ID card.

Specialty Pharmacy

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, cancer and multiple sclerosis. They often require careful adherence to treatment plans, have special handling or storage needs, and may only be stocked by select pharmacies. More information is available in the specialty pharmacy program member flier.

A split fill program may apply to some medications like select oral oncology (cancer), multiple sclerosis and iron toxicity drugs. This program lets you try the medication first to make sure you can tolerate any potential side effects. You will get a partial fill of your prescription and only pay for what was filled (a prorated cost of your benefits).

Coverage benefits and requirements may vary based on your plan benefits. Call the number on your Member ID card if you have any questions.

BCBSIL HMO members can fill their self-administered specialty drug prescriptions at an in-network specialty pharmacy for pharmacy benefit coverage consideration. To find an in-network specialty pharmacy near you, log in to your Blue Access for Members^SM account and click on the Prescription Drugs link. This will take you to Prime Therapeutics, the pharmacy benefit manager. You can find a list of in-network specialty pharmacies for Illinois HMO members in the Forms section.

Pharmaceutical Care Management

If you have BCBSIL prescription drug benefit coverage, you have access to our team of clinical pharmacists and other resource tools to help answer questions you may have about your prescriptions.

The Pharmaceutical Care Management (PCM) program helps you get the best results from the medicines you take. A member of the PCM team may reach out to talk with you about the medicines you take. The medication review by a clinical pharmacist helps make sure the medicines you are taking are safe and work well. The pharmacist can also share ways to help you lower your out-of-pocket costs for your prescriptions.

For more information about how PCM works:

Download the  PCM Program member flier.

Pharmacy Programs for HMO Members