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.
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.
Erectile Dysfunction (ED)
- Xyrem is also included in this program. See separate entry in Specialty Prior Authorization section.
Specialty Prior Authorization
Erythropoiesis Stimulating Agents (ESAs)
H.P. Acthar (Pituitary Hormone)
- H.P. Acthar Gel
Hepatitis B & C
Idiopathic Thrombocytopenic Purpura (ITP)
Inherited Autoinflammatory Disorders
Kalydeco (Cystic Fibrosis)
Pulmonary Arterial Hypertension (PAH)
Short Bowel Syndrome
Urea Cycle Disorders
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)
Diabetes (GLP-1 Receptor Agonists)
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)
Proton Pump Inhibitors — PPIs (Gastroesophageal Reflux Disease)
Specialty Step Therapy
Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis)
- Gonal F RFF
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.