As prescription drug costs continue to rise, employers, health plans and health care professionals are working together to find ways to manage medication use.
The HMO prior authorization (PA) and step therapy (ST) programs encourage the safe and cost-effective use of medication by allowing coverage when certain conditions are met. Blue Cross and Blue Shield of Illinois (BCBSIL) relies on a clinical team of physicians and pharmacists to identify, develop and approve the clinical programs and criteria for medications that are appropriate for prior authorization. The clinical team reviews FDA-approved labeling, scientific literature and nationally recognized guidelines.
The HMO PA and ST programs include management of the following medications:
Anabolic Steroids
- Anadrol
- Oxandrin
- Winstrol
Growth Hormones
- Genotropin
- Humatrope
- Norditropin
- Nutropin/AQ
- Saizen
- Serostim
Hepatitis C
- Copegus
- Pegasys
- Peg-Intron
- Rebetol
- Ribasphere
- Ribavirin
Hypertension
ACE Inhibitors
- Aceon
- Accupril
- Accuretic
- Altace
- Capoten
- Capozide
- Lotensin/HCT
- Mavik
- Monopril/HCT
- Prinivil
- Prinzide
- Uniretic
- Univasc
- Vaseretic
- Vasotec
- Zestoretic
- Zestril
ARBs
- Atacand/HCT
- Avalide
- Avapro
- Benicar/HCT
- Cozaar
- Diovan/HCT
- Hyzaar
- Micardis/HCT
- Teveten/HCT
Insomnia Step Therapy:
- Ambien
- Ambien CR
- Lunesta
- Sonata
- Rozerem
Oral Fentanyl Prior Authorization:
- Actiq
- Fentanyl lollipop
- Fentora
Rheumatoid Arthritis/Psoriasis
- Amevive
- Enbrel
- Humira
- Kineret
- Raptiva
When a member fills or refills a prescription for one of the medications listed above, the prescription claim will reject, and the pharmacy will receive a message stating that prior authorization is necessary. It will then be necessary for the physician to complete and submit a BCBSIL preauthorization request physician fax form. Continued use will be available if the patient's medical history and current medical condition warrant it.
For information about the prior authorization medical criteria for anabolic steroids and growth hormones, please review medical policies or the Rx clinical criteria.
If you have questions or concerns regarding these programs, please call the Pharmacy Program at (800) 423-1973.
ACE/ARB Fax Form (PDF, 35KB)
Amevive Fax Form (PDF, 37KB)
Anabolic Steroid Fax Form (PDF, 114KB)
Enbrel Fax Form (PDF, 37KB)
Growth Hormone Fax Form (PDF, 306KB)
Hepatitis C Fax Form (PDF, 40KB)
Humira Fax Form (PDF, 37KB)
Insomnia Agents Fax Form (PDF, 32KB)
Kineret Fax Form (PDF, 36KB)
Leukotriene Modifiers Fax Form (PDF, 29KB)
Oral Fentanyl Fax Form (PDF, 32KB)
Prior Authorization Program Member Brochure (PDF, 1.56MB)
Raptiva Fax Form (PDF, 36KB)
Step Therapy Program Member Brochure (PDF, 1.76MB)
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