Illinois House Bill 5395: Step Therapy
Nov. 12, 2025
Specifically applies to Individual & Family Markets, including PPO, HMO, POS, Grandfathered and Transitional; Student Health plans; Fully Insured, including Small Group, Mid-Market, Large Group, Municipality/County and the State Employees Plan, PPO, HMO, POS, Grandfathered and Transitional; ASO Municipality/County* and the State Employees Plan
The Illinois Healthcare Protection Act amends several provisions of the Illinois Insurance Code, including the Managed Care Reform and Patient Rights Act, and specifically step therapy and formulary requirements.
What you need to know: The bill requires drug formularies to be posted in a specific, publicly accessible and searchable format and prohibits formularies from imposing step therapy requirements.
What’s the impact to Blue Cross and Blue Shield of Illinois plans?
For groups with Prime Therapeutics® as their pharmacy benefits manager:
- We have completed our required formulary filings.
- We have posted our Fully Insured drug formularies in the template set by the Illinois Department of Insurance on bcbsil.com.
- Effective Jan. 1, 2026, impacted members will not be subject to step therapy.
Groups with a PBM other than Prime should check with their PBM to confirm compliance.
*Note: The formulary publication requirement does not apply to ASO Municipality/Counties.
Prime Therapeutics, LLC is a separate company Blue Cross and Blue Shield of Illinois contracts with to provide pharmacy solutions. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
*This article, or a similar version, is being shared with employer groups in the BlueVISIONSM newsletter or news alert.