Prescription Clinical Programs

The Prior Authorization and Step Therapy programs encourage safe, cost-effective medication use. These programs may be part of your prescription drug benefits. Log in to your member account  and review your prescription and pharmacy benefits to find out if your benefit plan has these programs.

Prior Authorization

This program requires your doctor to request pre-approval, or prior authorization, for you to get benefits for select medications.

• Your prescription drug benefits may have drug categories and specific drugs that require prior authorization.
• Some of those drug categories and examples of medications are listed below. Not all drug categories are included in your benefit plan. Additional drug categories may be added throughout the year.
  • Prior Authorization Program for Members on a “Metallic” Health Plan
  • Prior Authorization Program for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
  • Prior Authorization Program for Members on the Balanced Drug List
  • Prior Authorization Program for Members on the Performance (Quarterly and Annual) Drug List
  • Prior Authorization Program for Members on the Performance Select Drug List
• Your doctor can find request forms in the Provider section of our site.
• As always, cost is only one factor in choosing medication. Treatment decisions are between you and your doctor.
• Review the Prior Authorization member flier  for more information.
• Get answers to frequently asked questions about prescription prior authorization.
• Call the number on your member card with questions about a specific medication.

Step Therapy

The Step Therapy program requires that you use a “preferred” medication before your benefit plan will cover a “non-preferred” medication. The preferred medication is safe, works well in treating a specific medical condition, and is a cost-effective treatment option. A non-preferred medication could be a more costly prescription.

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

Step 2: If you and your doctor decide that a preferred medication is not right for you, or is not as good in treating your condition, your doctor should request a step-therapy exception to cover the non-preferred medication. Your doctor can find these request forms in the Provider  section of our site.

• The drug categories and examples of medications are listed below. Not all drug categories are included in your benefit plan. Additional categories may be added.
  • Step Therapy Programs for Members on a "Metallic" Health Plan
    
  • Step Therapy Programs for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
  • Step Therapy Programs for Members on the Balanced Drug List
  • Step Therapy Programs for Members on the Performance (Quarterly and Annual) Drug List
  • Step Therapy Programs for Members on the Performance Select Drug List 

• As always, cost is only one factor in choosing medication. Treatment decisions are between you and your doctor.
• Download the Step Therapy member flier  for more information about step therapy.
• Get answers to frequently asked questions about step therapy.
• Call the number on your member card with questions about a specific medication.

Prime Therapeutics LLC is a separate company contracted by Blue Cross and Blue Shield of Illinois to provide pharmacy solutions. Blue Cross and Blue Shield of Illinois, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC. MyPrime.com is a pharmacy benefit website offered by Prime Therapeutics LLC.