Pharmacy Programs for HMO Members

Medications with an equivalent available over-the-counter (OTC) are usually not covered through Blue Cross and Blue Shield of Illinois (BCBSIL) prescription drug plans.

Some facts to consider:

• You will not usually receive coverage for brand and generic prescription medications that have OTC versions available at the same prescription strength.
• You may still purchase the medication – either by prescription or over-the-counter – but you will be responsible for the full cost of the drug.
• Choosing to purchase the OTC version will often save you money.
• To see if a specific drug is part of the program, view the over-the-counter equivalent exclusion program drug list.
• If you have questions about the program, call the Pharmacy Program number listed on the back of your BCBSIL member ID card.
• Talk with your doctor before making any changes to your current medication regimen. As always, treatment decisions are between you and your doctor.

This program does not apply to members who have outpatient prescription drug coverage through their medical plan, processed by BlueSCRIPT^SM.

The 90-day supply benefit program can save you both time and money. With this program, you have the option of getting up to a 90-day supply of long-term (or maintenance) medications through a network of contracting extended supply retail and mail service pharmacies. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes.

For more information, download the 90-Day Supply Program Member Flier.

Getting Started

1. Ask your doctor for a prescription of a 90-day supply of each of your long-term medicines. 

2. To purchase your prescription:

• At a network “90-day” retail pharmacy – take your prescription to your pharmacy or have your doctor submit the prescription electronically. 
• Through mail order – order online, through a mobile device, over the phone or through the mail. You can find contact information for these pharmacies at myprime.com.
   

Tips for using mail order:

• If you need to start your prescription right away, ask your doctor for a one-month supply you can fill at a retail pharmacy. 
• If mailing your order, you can find a new prescription order form at myprime.com. Print and fill out the order form. Send the completed order form, your prescription and payment to the mail-order pharmacy. 
• Keep in mind that medicines can take up to 5 business days to deliver after the pharmacy receives and verifies your order.
   

The Prior Authorization and Step Therapy programs encourage safe, cost-effective medication use. These programs may be part of your prescription drug benefits. Refer to your benefit materials to find out if your benefit plan has these programs, as well as which medications are part of your plan.

Prior Authorization

This program requires your doctor to request pre-approval, or prior authorization, for you to get benefits for select medications.

• Your prescription drug benefits may have drug categories and specific drugs that require prior authorization.
• Some of those drug categories and examples of medications are listed below. Not all drug categories are included in your benefit plan. Additional drug categories may be added throughout the year.
  • Prior Authorization Program for Members on a “Metallic” Health Plan
    
  • Prior Authorization Program for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
  • Prior Authorization Program for Members on the Balanced Drug List
  • Prior Authorization Program for Members on the Performance (Quarterly and Annual) Drug List
  • Prior Authorization Program for Members on the Performance Select Drug List
• Your doctor can find request forms at bcbsil.com/provider.
• As always, cost is only one factor in choosing medication. Treatment decisions are between you and your doctor.
• Review the member flier for more information about Prior Authorization.
• Call the number on your member card with questions about a specific medication.
   

Step Therapy

The Step Therapy program requires that you use a “preferred” medication before your benefit plan will cover a “non-preferred” medication. The preferred medication is safe, works well in treating a specific medical condition, and is a cost-effective treatment option. A non-preferred medication could be a more costly prescription.

Step 1: If possible, your doctor should prescribe a preferred medication that is right for your condition.

Step 2: If you and your doctor decide that a preferred medication is not right for you, or is not as good in treating your condition, your doctor should submit a step-therapy exception to cover the non-preferred medication. Your doctor can find these request forms at bcbsil.com/provider.

• The drug categories and examples of medications are listed below. Not all drug categories are included in your benefit plan. Additional categories may be added.

• As always, cost is only one factor in choosing medication. Treatment decisions are between you and your doctor.
• Call the number on your member card with questions about a specific medication.
  • Step Therapy Programs for Members on a "Metallic" Health Plan
  • Step Therapy Programs for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
  • Step Therapy Programs for Members on the Balanced Drug List
  • Step Therapy Programs for Members on the Performance (Quarterly and Annual) Drug List
  • Step Therapy Programs for Members on the Performance Select Drug List

• As always, cost is only one factor in choosing medication. Treatment decisions are between you and your doctor.
• Download the member flier for more information about Step Therapy.

• Call the number on your member card with questions about a specific medication.

If you have questions about either the prior authorization or the step therapy programs, call the number listed on your member card.

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, cancer and multiple sclerosis. They often require careful adherence to treatment plans, have special handling or storage needs, and may only be stocked by select pharmacies. More information is available in the specialty pharmacy program member flier.

A split fill program may apply to some medications like select oral oncology (cancer), multiple sclerosis and iron toxicity drugs. This program lets you try the medication first to make sure you can tolerate any potential side effects. You will get a partial fill of your prescription and only pay for what was filled (a prorated cost of your benefits).

Coverage benefits and requirements may vary based on your plan benefits. Call the number on your Member ID card if you have any questions.

BCBSIL HMO members can fill their self-administered specialty drug prescriptions at an in-network specialty pharmacy for pharmacy benefit coverage consideration. To find an in-network specialty pharmacy near you, log in to your Blue Access for Members^SM account and click on the Prescription Drugs link. This will take you to Prime Therapeutics, the pharmacy benefit manager. You can find a list of in-network specialty pharmacies for Illinois HMO members in the Forms section.

If you have BCBSIL prescription drug benefit coverage, you have access to our team of clinical pharmacists and other resource tools to help answer questions you may have about your prescriptions.

The Pharmaceutical Care Management (PCM) program helps you get the best results from the medicines you take. A member of the PCM team may reach out to talk with you about the medicines you take. The medication review by a clinical pharmacist helps make sure the medicines you are taking are safe and work well. The pharmacist can also share ways to help you lower your out-of-pocket costs for your prescriptions.

For more information about how PCM works:

• Download the  PCM Program member flier.