Changes Coming to the Medical Drug Benefit Program
Oct. 14, 2026
Effective Jan. 1, 2027, we will update coverage for specific prescription drugs administered by a health care provider in a clinical setting.
The expanded Medical Drug Benefit Program defines coverage for select medical drugs and enhances access to cost-effective care for our commercial members. It does not apply to Medicaid, health maintenance organization, Federal Employee Program or Postal Employee Program members.
What’s included
- Therapeutic alternatives: Certain therapeutic equivalent or alternative drugs reviewed and determined to be clinically effective as noncovered products when used to treat the same condition. Members’ health plan benefits may only cover these therapeutic equivalent or alternative drugs.
- New-to-market drugs: Drugs that are newly approved by the U.S. Food and Drug Administration are not covered until reviewed and coverage determined by Blue Cross and Blue Shield of Illinois.
- FDA-accelerated approval indications: Drugs that have been approved through the FDA’s accelerated approval program are not covered until we review and determine coverage.
- Limited medical benefit coverage: Some drugs may only be covered for a set time, dose or number of treatments when a self-administered formulation of the drug is available.
For some members, the noncovered drug(s) and self-administered formulations may be covered through the prescription drug benefit. Members may request a coverage exception for a noncovered drug or self-administered formulation if the drug treatment is medically necessary.
Before submitting a prior authorization request, refer to the Medical Drug Benefit Program Summary to learn which drugs are included in the program. Our medical policies serve as clinical guidelines for coverage decisions.
Always check eligibility and benefits through our provider portal, Availity® Essentials, or your preferred vendor prior to rendering services. This step will confirm membership, prior authorization requirements and utilization management vendors, if applicable.
Prior authorization and exception requests
- Refer to utilization management and prior authorization for 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 drugs you’re recommending require prior authorization.
- If a drug is not covered under the Medical Drug Benefit Program, an exception may be requested by completing the Medical Drug Benefit Program exception form.
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.
BCBSIL makes no endorsement, representations or warranties regarding third party vendors.