Nov. 22, 2024
Effective Jan. 1, 2025, we will recommend some preferred drugs over other drugs according to our medical policies, when clinically appropriate. This will improve access to more affordable care for some of our commercial non-HMO members.
What’s changing? When submitting a prior authorization request for certain drugs, you will receive a recommendation for preferred drugs that are comparable and clinically appropriate. Blue Cross and Blue Shield of Illinois or Carelon Medical Benefits Management will process these prior authorization requests.
Before submitting a prior authorization request, you can learn which drugs are included in this process, and what preferred drugs will be recommended, by referring to our medical policies.
For Pegfilgrastim and biosimilars, see Medical Policy number RX501.134, “Oncologic Uses of White Blood Cell Colony Stimulating Factors,” for more information (medical policy disclosed Oct. 1, 2024).
For immunoglobulin therapy, see Medical Policy number RX504.003, “Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and Subcutaneous Ig [SCIG]),” for more information (medical policy disclosed Oct. 1, 2024).
For Rituximab and biosimilars, see Medical Policy number RX502.030, “Rituximab and Biosimilars for Non-Oncologic Indications,” (medical policy disclosed Oct. 1, 2024).
Always check eligibility and benefits first to confirm membership and other important information, including prior authorization requirements and utilization management vendors, if applicable.
For more details on prior authorization
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 drugs you’re recommending 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.
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.