June 2022
Pharmacy Prior Authorization Update: New Preferred Drug Recommendation Process
Effective Aug. 1, 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) will begin recommending some preferred drugs over other drugs through our medical policies, when clinically appropriate, to improve access to more affordable care for some of our commercial non-HMO members.
This change doesn’t apply to government programs (Medicare Advantage and Illinois Medicaid) or any of our HMO members.
What’s changing?
Medical policy criteria will indicate clinically appropriate preferred drugs. Before submitting a prior authorization request, you can find out which drugs are included in this process, and which preferred drugs will be recommended, by referring to BCBSIL’s Medical Policies.
The categories of drugs and impacted medical policies include:
- Medical oncology drugs – See BCBSIL Medical Policy Oncology Medications RX502.061 for more information.
- Osteoporosis therapies – See BCBSIL Medical Policy Denosumab (Prolia and Xgeva) RX501.140 for more information.
- Infliximab and biosimilars – See BCBSIL Medical Policy Infliximab and Associated Biosimilars RX501.051 (updated April 1, 2022) for more information.
- Enzyme replacement therapies – See BCBSIL Medical Policy Enzyme-Replacement Therapy for Lysosomal Storage Disorders RX501.067 (updated April 1, 2022) for more information.
Reminders and Resources
Always check eligibility and benefits first to confirm membership and other important information, including prior authorization requirements and utilization management vendors, if applicable. Regarding the preferred drug recommendation process referenced above, if prior authorization is needed, it will be processed by BCBSIL Medical Management or AIM Specialty Health® (AIM).
Other prior authorization resources are available in the Utilization Management section of our Provider website. Refer to the Prior Authorization page for step-by-step instructions on how to submit prior authorization requests. Also see the Prior Authorization Support Materials (Commercial) page for prior authorization code lists and links to our digital lookup tool.
Prescribing drugs using the enhanced prior authorization program referenced above helps to prevent claim denial if an exception does not apply.
Continue to watch the Blue Review and News and Updates for more information and future announcements.
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The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed 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 BCBSIL Medical Policies. Members should contact the customer service 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.
AIM Specialty Health (AIM) 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 and the products and services offered by them.