Blue Access for Producers

HMO Groups/Standard Products: Prior Authorization/Step Therapy Program

Blue Cross and Blue Shield of Illinois' (BCBSIL) prior authorization/step therapy program is designed to encourage safe, cost-effective medication use. Most HMO groups and standard products plans include this program.

Prior Authorization

Under this part of the program, the member's physician will be required to obtain authorization from BCBSIL in order for the member to receive benefits for certain medications and drug categories.

Below are drug categories and specific medications* for which a prior authorization program exists for most HMO group and standard products plan members. Please note that the drug categories and medications may change from time-to-time. For the most up-to-date list, members should call the Pharmacy Program number on the back of their BCBSIL ID card.

As always, cost is only one factor in choosing medication, and treatment decisions are between the member and physician.

Androgens/Anabolic Steroids

  • Anadrol-50
  • Androderm
  • Androgel
  • Android
  • Androxy
  • Axiron
  • danazol
  • Delatestryl
  • Depo-Testosterone
  • First-Testosterone
  • Fortesta
  • Methitest
  • Oxandrin
  • Striant
  • Testim
  • Testred
  • Vogelxo

Antifungal Agents

  • Noxafil
  • Vfend
 

Doxycycline/Minocycline

Doxycycline products:
  • Adoxa
  • Alodox
  • Avidoxy DK
  • Doryx (and generic equivalents)
  • doxycycline
  • Monodox
  • Morgidox Kit
  • Nicazeldoxy
  • Nutridox Kit
  • Ocudox Kit
  • Oracea
  • Oraxyl
  • Vibramycin
Minocycline products:
  • Dynacin
  • Minocin
  • Minocin Kit
  • Solodyn (and generic equivalents)
 

Erectile Dysfunction (ED)

  • Caverject
  • Cialis
  • Edex
  • Levitra
  • Muse
  • Staxyn
  • Stendra
  • Viagra

Fentanyl (Oral/Nasal)

  • Abstral
  • Actiq
  • Fentora
  • Lazanda
  • Onsolis
  • Subsys

Narcolepsy

  • Nuvigil
  • Provigil
  • Xyrem is also included in this program. See separate entry in Specialty Prior Authorization section.

Opioid Dependence

  • Bunavail
  • Suboxone
  • Subutex
  • Zubsolv

Specialty Prior Authorization

Cushing's Disease

  • Signifor

Enzyme Deficiency

  • Kuvan

Erythropoiesis Stimulating Agents (ESAs)

  • Aranesp
  • Epogen
  • Procrit

Familial Hypercholesterolemia

  • Juxtapid
  • Kynamro

Growth Hormone/Egrifta

  • Egrifta
  • Genotropin
  • Humatrope
  • Norditropin
  • Nutropin
  • Nutropin AQ
  • Omnitrope
  • Saizen
  • Serostim
  • Tev-tropin
  • Zorbtive

H.P. Acthar (Pituitary Hormone)

  • H.P. Acthar Gel

Hepatitis B & C

  • Incivek
  • Infergen
  • Olysio
  • Pegasys
  • PegIntron
  • Sovaldi
  • Victrelis

Huntington's Chorea

  • Xenazine

Idiopathic Thrombocytopenic Purpura (ITP)

  • Nplate
  • Promacta

Inherited Autoinflammatory Disorders

  • Arcalyst
  • Ilaris

Kalydeco (Cystic Fibrosis)

  • Kalydeco

Multiple Sclerosis

  • Ampyra

Osteoporosis

  • Forteo

Pulmonary Arterial Hypertension (PAH)

  • Adcirca
  • Letairis
  • Opsumit
  • Revatio
  • Tracleer

Self-Administered Oncology

  • Afinitor
  • Afinitor Disperz
  • Bosulif
  • Caprelsa
  • Cometriq
  • Erivedge
  • Gilotrif
  • Gleevec
  • Hexalen
  • Hycamtin
  • Iclusig
  • Inlyta
  • Imbruvica
  • Jakafi
  • Lysodren
  • Matulane
  • Mekinist
  • Nexavar
  • Oforta
  • Pomalyst
  • Revlimid
  • Sprycel
  • Stivarga
  • Sutent
  • Sylatron
  • Tafinlar
  • Tarceva
  • Targretin
  • Tasigna
  • Temodar
  • Thalomid
  • Tretinoin
  • Tykerb
  • Votrient
  • Xalkori
  • Xeloda
  • Xtandi
  • Zelboraf
  • Zolinza
  • Zykadia
  • Zytiga

Short Bowel Syndrome

  • Gattex

Urea Cycle Disorders

  • Buphenyl
  • Ravicti

Xyrem

  • Xyrem

Step Therapy

Step therapy is a type of prior authorization. In order for a member to receive coverage for drugs included in this part of the program, the physician will be required to obtain authorization from BCBSIL.

As an alternative to asking their doctor to receive prior authorization, or paying the entire cost of the medication out-of-pocket, members, along with their physician, may decide that a lower-cost generic or brand alternative medication that is not part of the program is an appropriate option. The plan will provide benefits for medications included in the program when the member first tries a lower-cost medication or the doctor obtains prior authorization of coverage through BCBSIL.

Below are drug categories and specific medications* for which a step therapy program exists for most HMO group and standard products plan members. Step therapy does not apply to the generic equivalents for these medications (if available). If the member and physician decide the generic equivalent is an appropriate option, the member will not need to go through the prior authorization process. Please note: These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.

Please note that the drug categories and medications may change from time-to-time. For the most up-to-date list, members should call the Pharmacy Program number on the back of their BCBSIL ID card.

As always, cost is only one factor in choosing medication, and treatment decisions are between the member and doctor.

Cox-2/NSAID GI Protectant (Pain Management)

  • Celebrex
  • Duexis
  • Vimovo

Depression

  • Aplenzin
  • Brintellix
  • Celexa
  • Cymbalta
  • Desvenlafaxine ER tabs
  • Desvenlafaxine fumarate
  • Effexor
  • Effexor XR
  • Fetzima
  • fluoxetine 60 mg tabs
  • Forfivo XL
  • Lexapro
  • Luvox CR
  • maprotiline
  • Oleptro
  • Paxil
  • Paxil CR
  • Pexeva
  • Pristiq
  • Prozac
  • Prozac Weekly
  • Remeron
  • Remeron SolTab
  • venlafaxine ER tabs
  • Viibryd
  • Viibryd Starter Kit
  • Wellbutrin
  • Wellbutrin SR
  • Wellbutrin XL
  • Zoloft

Diabetes (GLP-1 Receptor Agonists)

  • Bydureon
  • Byetta
  • Tanzeum
  • Victoza

Glucose Test Strips

  • All non-formulary brand test strips and disks (Standard Formulary brands are Bayer and Roche; Generics Plus Formulary brand is Bayer)

Lipid Management (Cholesterol)

  • Advicor
  • Altoprev
  • Lescol
  • Lescol XL
  • Lipitor
  • Liptruzet
  • Livalo
  • Mevacor
  • Pravachol
  • Simcor
  • Vytorin
  • Zocor

Proton Pump Inhibitors — PPIs (Gastroesophageal Reflux Disease)

  • Aciphex
  • Dexilant
  • Esomeprazole Strontium
  • First lansoprazole suspension kit
  • First omeprazole suspension kit
  • Nexium
  • omeprazole/sodium bicarbonate
  • Prevacid
  • Prilosec
  • Protonix
  • rabeprazole
  • Zegerid

Specialty Step Therapy

Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis)

  • Actemra subcutaneous
  • Cimzia
  • Enbrel
  • Entyvio
  • Humira
  • Kineret
  • Orencia subcutaneous
  • Otezla
  • Simponi
  • Stelara
  • Xeljanz

Infertility**

  • Gonal
  • Gonal F RFF

Iron Chelator

  • Ferriprox

Multiple Sclerosis

  • Aubagio
  • Avonex
  • Extavia
  • Gilenya

More information is available in the Prior Authorization Program Member Flier  and Step Therapy Program Member Flier .

Members should call the Pharmacy Program number on the back of their BCBSIL ID card with questions about the prior authorization/step therapy program.


* Third-party brand names are the property of their respective owners.

** The infertility step therapy program does not apply for standard HMO plans.