This page may have documents that can’t be read by screen reader software. For help with these documents, please call 1-800-203-3765.
Under the Prior Authorization Program, your doctor needs approval from Blue Cross and Blue Shield of Illinois before your prescription drug plan will cover certain medications and drug categories.
The Step Therapy Program encourages safe, cost-effective medication use by requiring you to have a prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug.
A first-line drug is recognized as safe and effective in treating a specific medical condition, as well as being a cost-effective treatment option. A second-line drug is a less-preferred or potentially more costly treatment option.
Check the Basic Drug List or visit MyPrime to see if any special requirements apply for your drug(s). If you're a current member and have recently gone through the Step Therapy Program for a particular drug, you don't have to complete it again.
Specialty medications include those used in the treatment of complex medical conditions. Examples include hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis.
Through the Prime Specialty Pharmacy, you can have self-administered specialty drugs delivered directly to you or your doctor's office.*
View the Specialty Pharmacy Program Drug List which includes a reminder about coverage for self-administered specialty medications.
Note: If you use a manufacturer’s coupon to help reduce how much you pay for a specialty drug, the value of that coupon will not be applied toward your coinsurance (or deductible, if you have a High Deductible Heath Plan) and yearly out-of-pocket (OOP) maximum.
To order through Prime Specialty Pharmacy:
*A Prime Specialty Pharmacy coordinator will contact you to arrange delivery of your medication with each order.
Some brand-name drugs are also available in a generic version. If your medication is available in a generic version with the same active ingredients and at the same dosage you'll pay more if you choose to buy the brand-name version. In that case, you'll pay your higher copayment or coinsurance amount, plus the difference in cost between the brand drug and its generic equivalent. When you can, buying the generic version can often save you money.
Keep in mind medications that can also be found over-the-counter (OTC) are usually not covered through your prescription drug plan, even if your doctor has prescribed it. Because these drugs are not covered under your plan, buying the OTC version can often save you money.
To help ensure safe drug usage, there are rules put on certain medications. These rules affect:
These limits reflect generally accepted pharmaceutical manufacturers' guidelines and help encourage medication use as intended by the U.S. Food and Drug Administration (FDA).
For more information, view Dispensing Limits.