December 18, 2023
Blue Cross and Blue Shield of Illinois is committed to providing its members access to safe, appropriate and cost-effective health care within their plan benefits. To ensure the appropriate use of GLP-1s as indicated for diabetes, we’re making it easier for some of our members with diabetes to bypass our prior authorization process.
Beginning Jan. 1, 2024, members using a GLP-1 diabetes drug who don’t have a diabetes diagnosis and other diabetes medication history on file will be required to go through the PA process. This will apply to both group members with prescription drug benefits administered by Prime Therapeutics and members who purchase individual and family plans, who have the PA program as part of their pharmacy benefits.
- If your patient doesn’t have a Type 2 diabetes diagnosis in their medical claims history and prescription history for other diabetes drugs, you may need to submit documentation of the missing information to meet the new PA criteria. Coverage of a GLP-1 diabetes drug may not be approved without documentation of a diabetes diagnosis.
- Note: If your patient has an existing PA approval for a GLP-1 diabetes drug, the PA will remain in effect until the expiration date stated on the PA approval notice. You, or your patients, may receive a PA notification alert to re-submit the request in advance as part of our notification process.
Medicaid members have similar requirements, requiring a Type 2 diabetes medical diagnosis and claims history of other diabetes medications for coverage consideration of the GLP-1 diabetes drugs.
Starting in 2024, Medicare members will also need PA approval for GLP-1 coverage consideration to treat Type 2 diabetes. If a diagnosis of Type 2 diabetes is already on file with us, this request may not be needed.
BCBSIL and Prime Therapeutics continue to monitor market changes, abnormal pharmacy dispensing and medication utilization. Pharmacy clinical management strategies will be adjusted as needed to best support our members while managing the total cost of care.
BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. MyPrime.com is an online resource offered by Prime Therapeutics.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.