Prior authorization (PA) and step therapy (ST) encourage safe, cost-effective medication use by allowing coverage when certain conditions are met. A team of physicians and pharmacists develops and approves the clinical programs and criteria for medications that are appropriate for PA and ST by reviewing U.S. Food and Drug Administration (FDA) approved labeling, scientific literature and nationally recognized guidelines.
Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of PA and ST requests from physicians for Blue Cross and Blue Shield of Illinois (BCBSIL) members with prescription drug coverage.
Physicians must complete and submit a request form for all PA and ST medications. Benefits will apply if the member meets specified criteria. If criteria are not met, the member may still choose to receive the medication and will be responsible for the full cost. The final decision regarding what medicines should be prescribed, regardless of benefit determination, is a decision between the patient and their physician.
Not all prescription drug benefit plans include the PA/ST program, and the drug categories may vary depending on the member’s plan. If there are questions regarding prescription benefit coverage, please call the phone number on the back of the member’s BCBSIL ID card.
Program Criteria Summaries and Request Forms
Physicians can access, complete and submit the uniform PA form . Here are instructions for completing and submitting this uniform PA form.
For help completing section H (other pertinent information) of the uniform PA form, download the PA program criteria summaries from the Prime Therapeutics website using the following link:
Electronic request forms are on the CoverMyMeds® website:
Or, download ST program criteria summaries and fax forms from the Prime Therapeutics website using the following link:
If you have questions or concerns regarding these programs, please call Prime Therapeutics at 800-285-9426. Review the prior authorization/step therapy program list for a listing of all programs included in our standard utilization management package.
Illinois Mandated $0 Cost Share Products
Illinois Public Acts 102-1117 and 103-0462 (House Bill 4664 and Senate Bill 1344) are a reproductive rights and gender affirming care legislation that amends existing insurance code and requires in scope health plans to cover abortifacient medications, hormonal therapy for gender dysphoria and HIV pre-and post-exposure prophylaxis without cost sharing. Members of high-deductible health plans must meet their deductibles before certain services are covered without cost sharing, per Internal Revenue Service rules. Based on a member’s benefit plan, abortifacient medication, hormonal therapy for gender dysphoria, HIV pre-exposure prophylaxis and/or post-exposure prophylaxis drug(s) may be covered at no charge to the member, when obtained from a participating pharmacy. If your patients have questions about the drugs covered under this legislation, you may refer them to the No-Cost Reproductive Rights, HIV PrEP and PEP and Gender Affirming Care Drug List. To request a copay waiver exception for a drug processing with a cost-share, download the copay waiver form from the Prime Therapeutics website (select the patient’s prescription drug list). For help completing the form, there is also a criteria summary.
CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the products or services they offer, you should contact the vendor(s) directly.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSIL, as well as other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.
BCBSIL reserves the right to make exceptions to pharmacy program criteria that benefit the member when new medical information becomes available. When using pharmacy criteria to determine whether a medication will be covered, please note that member contract language will take precedence over the criteria when there is a conflict.
The purpose of the pharmacy criteria is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment.