Pharmacy Program Updates: Prior Authorization Changes Effective Nov. 1, 2022

September 2, 2022

The Blue Cross and Blue Shield of Illinois (BCBSIL) 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 BCBSIL members who have prescription drug benefits administered by Prime Therapeutics.

Please visit the Prior Authorization and Step Therapy Programs section for a list of programs and target drugs, as well as the PA 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 BCBSIL member ID card. Members may also visit  our member site and log in to Blue Access for Members^SM (BAM^SM) 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.

Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. If you have any questions, call the number on the member's BCBSIL ID card.