May 26, 2022
The prior authorization (PA) program encourages safe, cost‑effective medication use by allowing coverage when certain conditions are met. A clinical team of physicians and pharmacists develops and approves the clinical programs and criteria for medications that are appropriate for PA by reviewing U.S. Food and Drug Administration (FDA) approved labeling, scientific literature and nationally recognized guidelines.
Please see the table below for upcoming changes to the standard PA programs. These changes impact Blue Cross and Blue Shield of Illinois (BCBSIL) members who have prescription drug benefits administered by Prime Therapeutics.
|Description of Change
|PA or Specialty PA
|Aug. 1, 2022
|Erythropoiesis Stimulating Agents (ESA)
|New criteria requirements
|Basic, Basic Annual, Enhanced, Enhanced Annual, 2021 Health Insurance Marketplace (HIM), 2022 HIM, Balanced, Performance, Performance Annual and Performance Select
Please visit the Prior Authorization Step Therapy Programs section for a list of programs and target drugs, as well as the request form and more information.
As a reminder, treatment decisions are always between you and your patients. Coverage is subject to the terms and limits of your patients’ benefit plans. Please advise them to review their benefit materials for details.
If your patients have any questions about their pharmacy benefits, please advise them to contact the number on their member ID card. Members may also visit our member site and log in to Blue Access for MembersSM (BAMSM) or MyPrime.com for a variety of online resources.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime Therapeutics.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.