Pharmacy Programs for HMO Members

These Pharmacy Programs are available 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 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 PDF Document.
  • If you have questions about the program, call the Pharmacy Program number on the back of your 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 BlueSCRIPTSM.

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 obtaining 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.

Ordering Through PrimeMail

  • When you log in to Blue Access for Members and visit your Rx Drugs page, you can use the online order form, print an order form to mail or ask that PrimeMail get in touch with your doctor to request a new prescription.

For more information, download the PrimeMail flier PDF Document.

Ordering Through Walgreens Mail Service

  • When you log in to Blue Access for Members and visit your Rx Drugs page, you can use the online order form or ask that Walgreens Mail Service get in touch with your doctor to request a new prescription.

For more information, download the Walgreens Mail Service brochure PDF Document.

If you have questions about the 90-day supply program, call the Pharmacy Program number on the back of your ID card.

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 plan materials, or call the number on the back of your ID card.

Prior Authorization

Under this program, your doctor will be required to request pre-approval, or prior authorization, through Blue Cross and Blue Shield of Illinois in order for you to get benefits for select drugs.

More information is available in the prior authorization member flier PDF Document.

Step Therapy

The step therapy program requires that you have a 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 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 prior authorization request for coverage of the other drug.

More information is available in the step therapy member flier PDF Document.

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

Specialty Pharmacy

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis. These drugs are typically given by injection, but may be topical or taken by mouth. They often require careful adherence to treatment plans, have special handling or storage requirements, and may not be stocked by retail pharmacies.

BCBSIL HMO members can fill their self-administered specialty drug prescriptions at an in-network specialty pharmacy for pharmacy benefit coverage consideration. Log in to your Blue Access for MembersSM account to find a network specialty pharmacy near you.