The prior authorization/step therapy program at Blue Cross and Blue Shield of Illinois (BCBSIL) is designed to encourage safe, cost-effective medication use. Most HMO groups and standard products plans include this program. Self-insured and custom fully insured groups offer a variety of these programs to help effectively manage their prescription drug benefit.
Under this program, the member's physician will be required to obtain authorization from BCBSIL in order for the member to receive benefits for certain medications and drug categories. Not all drug categories are included in all plans, and medications may change from time-to-time.
Step therapy is a type of prior authorization. In order for a member to receive coverage for drugs included in this program, the physician will be required to obtain authorization from BCBSIL.
As an alternative to asking their doctor to receive prior authorization, or paying the entire cost of the medication out-of-pocket, members, along with their physician, may decide that a lower-cost generic or brand alternative medication that is not part of the program is an appropriate option. The plan will provide benefits for medications included in the program when the member first tries a lower-cost medication, or the doctor obtains prior authorization of coverage through BCBSIL.
Step therapy does not apply to the generic equivalents for these medications (if available). If the member and physician decide the generic equivalent is an appropriate option, the member won't need to go through the prior authorization process.
Not all drug categories are included in all plans, and medications may change from time-to-time. For the most up-to-date list, members should call the Pharmacy Program number listed on their BCBSIL member ID card.
As always, cost is only one factor in choosing medication, and treatment decisions are between the member and doctor.