Jan. 26, 2026
Effective Jan. 1, 2026, we’re updating coverage for specific prescription medications administered by a health care provider in a clinical setting. We identified therapeutic equivalents or alternatives for these medications that have been reviewed and determined to work just as well as the non-covered product.
The Medical Benefit Therapeutic Alternatives program is designed to enhance access to cost-effective care for some of our commercial members.
What’s changing? Members’ health plan benefits may only cover select therapeutic equivalent or therapeutic alternative drugs. Blue Cross and Blue Shield of Illinois or Carelon Medical Benefits Management will process these prior authorization requests.
Before submitting a prior authorization request, refer to the Medical Benefit Therapeutic Alternatives Summary to learn which drugs are included. Our medical policies serve as the guidelines for coverage decisions.
Always check eligibility and benefits first through Availity® Essentials or your preferred vendor prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
For more details on prior authorization and exception requests
- Refer to utilization management and prior authorization for step-by-step instructions on how to submit prior authorization requests
- In addition to checking eligibility and benefits, refer to prior authorization support materials (commercial) for prior authorization code lists and links to our digital lookup tool to determine if the recommended drugs require prior authorization
Medical policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are encouraged to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize medical policies. Members should contact the number on their member ID card for more specific coverage information.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider.
Certain prescription drugs given to you by a health care provider in a clinical or professional setting have therapeutic equivalents or therapeutic alternatives that are used to treat the same condition. Your health plan benefits may only cover select therapeutic equivalent or therapeutic alternative drugs (“Medical Benefit Therapeutic Alternatives”). Learn more
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL.
Carelon Medical Benefits Management (formerly AIM Specialty Health) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third party vendors.