Obtain prior authorization for drugs marked “PA”

Certain medications listed on the formulary require prior authorization (PA); when a drug line shows “PA” in the Coverage Requirements and Limits column the provider must obtain an approved prior authorization before the medication will be covered. A PA approval is valid for the lesser of six months or the length of treatment (maintenance meds: lesser of 12 months or length of treatment).

• PA appears next to drugs in the Coverage Requirements and Limits column; obtain PA before dispensing when shown.
• PA validity: lesser of 6 months or length of treatment; maintenance meds: lesser of 12 months or length of treatment.

Review monthly UM changes (PA/QL updates)

This month’s monthly change chart includes utilization management updates — for example CTEXLI (chenodiol) had PA and a QL added and several ondansetron/granisetron strengths had QL removals; providers should review the monthly change chart for added PA/QL changes that may affect current prescriptions.

• CTEXLI (chenodiol 250 mg) — UM change: PA and QL added.
• Selected ondansetron and granisetron strengths — UM change: QL removed.
• BCBSIL updates the drug list monthly; check the chart for current PA/QL changes.

New specialty/high-tier drugs assigned Tier 3 or Tier 4

Numerous newly added specialty or high-tier drugs were assigned Tier 3 or Tier 4 (examples include GOMEKLI, OMVOH, SPEVIGO, TRYNGOLZA); expect these products to carry specialty handling and potential utilization controls.

• GOMEKLI additions show New Tier = Tier 4.
• OMVOH and other biologics added with Tier 3 or Tier 4 assignments.
• Tier increases may affect member cost share and prior authorization expectations.

Obtain PA for listed topical lidocaine products

Selected topical lidocaine products list PA and QL on their drug lines (e.g., Lidocaine Ointment 5% = PA, QL 120 g/30 days; Lidocaine Patch 5% = PA, QL 120 patches/30 days); obtain prior authorization and document expected days’ supply before dispensing.

• Lidocaine Oint 5% — Coverage Requirements and Limits = PA, QL (120 grams/30 days).
• Lidocaine Patch 5% — Coverage Requirements and Limits = PA, QL (120 patches/30 days).

PA required for selected specialty/high-cost agents

Several specialty or high-cost agents are annotated with PA (examples: ARIKAYCE — LD, PA, QL; TOBI PODHALER — PA, QL; EPIDIOLEX and FINTEPLA entries also show PA); providers must obtain prior authorization for these agents prior to coverage and follow limited distribution/specialty channel requirements where indicated.

• ARIKAYCE — Coverage Requirements and Limits = LD, PA, QL (235.2 mls/28 days).
• TOBI PODHALER — Coverage Requirements and Limits = PA, QL (224 capsules/56 days).
• EPIDIOLEX/FINTEPLA and other high-cost agents are listed with PA in formulary excerpts.

PA required for ER/sprinkle formulations labeled “PA”

Extended‑release, ER, or sprinkle formulations shown with “PA” on the formulary require prior authorization before coverage; review each product line for PA and supporting documentation when dispensing these formulations.

• Topiramate ER sprinkle formulations and other ER/sprinkle products are listed with PA and QL where applicable.
• Follow PA program and submit required documentation for ER/sprinkle formulations flagged PA.

Obtain PA for listed antifungals and migraine biologics

Selected antifungals and migraine agents require prior authorization per their formulary entries (e.g., CRESEMBA is listed with PA; migraine biologics such as AIMOVIG/EMGALITY/AJOVY require PA and have QL limits).

• CRESEMBA (isavuconazonium) — Coverage Requirements and Limits = PA.
• AIMOVIG, AJOVY, EMGALITY — Coverage Requirements and Limits include PA and product-specific QL (for example AIMOVIG PA, QL 1 injection/28 days).

Obtain PA when “PA” appears next to product

Multiple formulary entries include a “PA” indicator; providers must obtain prior authorization for those drugs prior to coverage — check each drug line for the PA flag and submit PA documentation accordingly.

• When a drug line shows PA, prior authorization is a coverage prerequisite.
• Submit required clinical documentation as described in the PA program.

Submit PA + clinical documentation for PA‑flagged products

When PA is indicated on a drug line (common for many oral oncology and specialty medications), providers must submit a prior authorization request and supporting clinical documentation to secure coverage; limited distribution products may also require specialty channel fulfillment.

• Oral oncology entries frequently list LD and PA — use designated specialty channels and submit PA.
• Provide indication, dosing, and prior therapy documentation to support PA requests.

PA required where PA flag is shown — claims may be denied without it

If a drug’s Coverage Requirements list PA, providers must obtain prior authorization before dispensing; failure to secure an approved PA may result in claim denial for that agent.

• Coverage flags such as PA denote programmatic controls that must be satisfied for coverage.
• Claims for PA‑designated drugs may be denied without an approved PA.

Obtain PA for GLP‑1/tirzepatide agents where shown

Examples in the GLP‑1/tirzepatide class show prior authorization requirements (MOUNJARO, OZEMPIC, TRULICITY are listed with PA and specific quantity limits); obtain PA and observe QL when prescribing these agents.

• MOUNJARO — Coverage Requirements and Limits = PA, QL (4 pens/28 days or 180 days per presentation).
• OZEMPIC — Coverage Requirements and Limits = PA, QL (1–3 pens/28 days depending on presentation).
• TRULICITY — Coverage Requirements and Limits = PA, QL (4 pens/28 days).

TRULICITY (and select GLP‑1s) require prior authorization

Prior authorization is required for select GLP‑1 agents such as TRULICITY which is listed with Coverage Requirements = PA and QL (4 pens/28 days); submit PA and include documentation supporting indication and dosing.

• TRULICITY — PA required; QL = 4 pens/28 days.
• Provide clinical rationale and prior therapy details when requesting PA.

PA required for selected hematopoietic and coagulation agents

Many hematopoietic growth factors, pegfilgrastim biosimilars, darbepoetin products and related supportive agents are designated PA (and often SP/LD); obtain prior authorization and adhere to listed quantity limits when requesting coverage.

• ARANESP/pegfilgrastim biosimilars — SP/PA designations present.
• HEMLIBRA — Coverage Requirements and Limits = LD, PA, QL (4 vials/28 days) for some listings.

Follow step therapy (ST) when indicated; exceptions may be requested

Some drugs on the formulary are subject to step therapy (ST); where “ST” appears in the Coverage Requirements and Limits column providers should follow the step program and may request an exception if clinical criteria are met.

• ST is indicated in the formulary key — follow product‑specific step therapy requirements when shown.
• Providers may request step therapy exceptions; BCBSIL reviews exceptions per program rules.

Check monthly updates for new utilization review restrictions

The formulary is updated monthly and may introduce new utilization review (UR) restrictions including PA and QL; providers should check the monthly change chart to confirm whether new UR controls apply to a prescribed drug.

• Monthly change chart lists additions, tier moves, and new UM restrictions.
• BCBSIL provides at least 60 days’ notice for tier increases, exclusions, or stricter UR for affected members.

Step therapy flags present — consult product lines for specifics

The drug list key includes ST (Step Therapy) flags; specific step therapy rules are not detailed in this excerpt, so providers must refer to each product line or the full formulary for applicable step sequences and requirements.

• KEY shows ST = Step Therapy; product rows with ST apply step requirements.
• When ST appears next to a drug, follow the listed step program in the full formulary.

Adhere to step therapy for agents marked “ST” (e.g., FETZIMA, TRINTELLIX)

Step therapy is defined in the formulary key and applies where “ST” appears next to specific drugs (examples in the extract: FETZIMA and TRINTELLIX show ST); follow the product‑specific ST requirements for those agents.

• FETZIMA (levomilnacipran) — Coverage Requirements and Limits = ST.
• TRINTELLIX (vortioxetine) — Coverage Requirements and Limits = ST.

ST flagged entries — seek full formulary for step sequences

Some formulary entries include an ST indicator but the excerpt does not show explicit step therapy chains; providers must consult the full formulary or product‑level rules for required prior agents and exception procedures.

• ST appears in the KEY but step sequences are not shown in these chunks.
• Use the full drug list/product entry to determine required prior therapies.

Observe step therapy indicators where present

Agents marked with “ST” in the key or next to the drug require adherence to step therapy when applicable; specific ST instructions are provided on the individual drug lines elsewhere in the formulary.

• Presence of ST in the key indicates step therapy may apply to some items.
• Follow product-specific ST entries in the full formulary for enforcement.

Step therapy applies to selected antidepressants (FETZIMA, TRINTELLIX)

FETZIMA (levomilnacipran) and TRINTELLIX (vortioxetine) are listed with Step Therapy (ST) in their Coverage Requirements and Limits; follow ST program requirements and documentation processes when prescribing these antidepressants.

• FETZIMA — Coverage Requirements and Limits = ST.
• TRINTELLIX — Coverage Requirements and Limits = ST.

Submit exceptions when clinically appropriate for ST-flagged drugs

Where the formulary indicates “ST” for a product, providers must abide by the step therapy protocol in the full formulary; this excerpt notes ST presence but not the detailed chains — request a step therapy exception if clinically justified.

• ST is indicated in the KEY; product-specific ST rules appear in full drug entries.
• Exception requests may be submitted and will be adjudicated per BCBSIL rules.

ST is noted in key — consult product entries for step details

The formulary key shows ST flags but does not include specific step sequences in this excerpt; providers must check individual drug listings or the full formulary for any required prior steps.

• ST appears in the KEY; consult the product line for step details.
• Monthly updates may add ST requirements for specific drugs.

Follow ST requirements for products annotated ST (e.g., risperidone ODT)

Some products are marked with the step therapy flag (ST) in the KEY (examples: risperidone ODT shows QL and ST); observe ST where shown and provide documentation of prior therapy or medical rationale if requesting an exception.

• Risperidone ODT — Coverage Requirements and Limits = QL (60 tablets/30 days), ST.
• When ST is present, include prior therapy records or rationale with exception requests.

Submit PA requests via BCBSIL provider forms or phone

When the formulary indicates PA for a product, providers must submit prior authorization requests using BCBSIL forms available at bcbsil.com/provider or by calling the number on the member ID card.

• PA forms and submission instructions available at bcbsil.com/provider or via the phone number on the member ID card.
• For expedited or standard exception/PA processing timelines see the Exception Process section.

Use copay waiver / coverage exception forms on bcbsil.com or myprime.com

Copay waiver and coverage exception forms (including for ACA preventive or No‑Cost Preventive Drug List items) are available at bcbsil.com/provider or myprime.com; use these forms when requesting a copay waiver or coverage exception.

• Copay waiver and coverage exception forms are on bcbsil.com/provider and myprime.com.
• Follow the ACA preventive guidance when submitting copay waiver requests.

Submit coverage exceptions — decision timelines (72 hrs standard, 24 hrs expedited)

Coverage exception requests may be submitted by the member, prescriber, or authorized representative; BCBSIL will notify the decision within 72 hours for standard requests or within 24 hours for expedited (urgent) requests.

• Standard exception decision timeframe = 72 hours.
• Expedited (urgent) exception decision timeframe = 24 hours.

Adhere to dispensing QLs for analgesics/NSAIDs when billing

Selected analgesics and NSAIDs include explicit quantity limits (QL) that must be followed when submitting pharmacy claims (e.g., celecoxib 50/100/200 mg = QL 60 caps/30 days; ketorolac 10 mg = QL 20 tablets/30 days); ensure days‑supply and quantity conform to QL.

• Celecoxib 50/100/200 mg — QL 60 capsules/30 days; celecoxib 400 mg — QL 30 capsules/30 days.
• Ketorolac tromethamine 10 mg — QL 20 tablets/30 days.

Document dispensing for CW (cost‑waived) opioid reversal agents

Certain opioid reversal agents are designated CW (Cost Waived) under Illinois mandate (e.g., naloxone nasal sprays, prefilled syringes); documentation of dispensing may be required per program rules to support cost‑waived handling.

• Naloxone nasal sprays and prefilled syringes appear with Coverage Requirements and Limits = CW.
• Pharmacies should document dispensing per program guidance to support cost‑waived coverage.

Provide documentation supporting dispensed quantity vs. listed QL

Quantity limits (QL) are specified for many formulary agents (e.g., ARIKAYCE QL 235.2 mL/28 days, TOBI PODHALER QL 224 capsules/56 days); include expected days‑supply or units in documentation to support dispensing when requesting authorization for quantities near the QL.

• ARIKAYCE — QL 235.2 mL/28 days.
• TOBI PODHALER — QL 224 capsules/56 days.
• Linezolid tab 600 mg — QL 56 tablets/180 days.

Include clinical documentation to support PA and QL requests

For drugs flagged PA or QL, providers must include documentation that supports medically necessary dosing and indication when submitting prior authorization or exception requests to avoid denial.

• Include diagnosis, prior therapies, and dose/days‑supply justification with PA requests.
• Documentation expectations apply to formulations noted with PA or QL.

PA and QL for migraine biologics (AIMOVIG, EMGALITY, etc.)

Certain migraine biologics require PA and have explicit quantity limits (e.g., AIMOVIG = PA, QL 1 injection/28 days; EMGALITY = PA, QL varies by presentation); obtain PA and follow QL when prescribing these agents.

• AIMOVIG — Coverage Requirements and Limits = PA, QL (1 injection/28 days).
• EMGALITY — Coverage Requirements and Limits = PA, QL (1 syringe/28 days or 9 syringes/180 days per presentation).

Use specialty/limited distribution channels and obtain PA for LD/OC drugs

For drugs designated LD (Limited Distribution) or OC (Oral Cancer Medications), providers may need to use specified specialty channels or limited distribution pharmacies and must obtain prior authorization when indicated.

• LD and OC designations frequently accompany PA and QL flags for oncology agents.
• Use required specialty distribution channels for LD products to secure fulfillment and coverage.

Provide indication and prior‑therapy documentation with PA requests

When a drug line lists PA, prescribers must submit supporting documentation (indication, dosing, prior therapies) with the prior authorization request to substantiate medical necessity and secure coverage.

• Provide indication, prior therapy history, and dosing schedule with PA submissions.
• PA program requirements and forms available on the BCBSIL provider site.

Adhere to product QLs (e.g., insulin 100 mL/30 days) to avoid member liability

Ensure dispensing aligns with the product‑specific quantity limits (QL) listed on the formulary (e.g., many insulins QL 100 mL/30 days; SYNJARDY QL 60 tablets/30 days); dispensing beyond QL may require prior authorization or result in member financial liability.

• Insulins (FIASP, HUMALOG, HUMULIN N) — Coverage Requirements and Limits = IC, QL (100 mL/30 days).
• SYNJARDY/SYNJARDY XR — QL 60 tablets/30 days.
• Exceeding QL may leave the member responsible for full cost of excess quantity.

Dispensing beyond QL may leave member financially responsible

If the dispensed quantity exceeds the plan's dispensing limit, the member may be responsible for the full cost of the prescription beyond what coverage allows; verify QL before dispensing and obtain PA if an exception is clinically required.

• Dispensed quantity beyond QL may result in no benefits applied for the excess.
• Obtain PA or coverage exception to mitigate member financial exposure when clinically necessary.

Claims may be denied without required prior authorization

Claims for medications listed with a PA flag may be denied if an approved prior authorization is not in place; verify PA requirements at point of prescribing/dispensing and submit PA in advance to avoid denial.

• PA indicated on drug lines must be obtained prior to dispensing to secure coverage.
• Lack of PA when required can trigger claim denial.

UM changes (QL removals/additions) may affect authorization

UM changes this cycle included QL removals for select ondansetron and granisetron strengths and QL additions for nilotinib 200 mg; these changes can affect authorization and coverage for affected strengths — confirm current QL before fulfilling prescriptions.

• Granisetron HCl 1 mg — UM change: QL Removed.
• Nilotinib HCl cap 200 mg — UM change: QL Added.

PA required for topical products flagged PA (denial risk if not obtained)

Topical products flagged PA (e.g., Lidocaine Oint 5%) require prior authorization; dispensing without PA when PA is indicated may result in denial of coverage for that product.

• Lidocaine Oint 5% — PA and QL listed; obtain PA before dispensing.
• Lack of PA for PA‑flagged topical products can trigger denial.

Verify PA at point of dispensing for PA‑flagged drugs

Products flagged PA at the point of dispensing will require an approved prior authorization; ensure the pharmacy point‑of‑sale has a valid PA to prevent claim rejection or denial.

• PA is enforced at dispensing when flagged on the drug line.
• Verify PA status at point of sale to avoid denial.

Use required specialty/limited distribution channels for LD/SP drugs

Limited Distribution (LD) and Specialty (SP) designations indicate specific handling and distribution channels; if the required specialty channel or LD process is not followed the product may not be fulfillable or covered.

• LD/ SP products (e.g., ARIKAYCE) require specialty fulfillment and associated PA/QL.
• Follow specialty vendor/LD instructions to secure coverage and delivery.

PA/QL flags are potential denial triggers — confirm before dispensing

Formulations or products marked with PA or with specific QL are potential denial triggers if requirements are not met; review each drug line for PA/QL prior to dispensing to avoid denials.

• PA or QL flags on the formulary indicate administrative controls that must be satisfied.
• Noncompliance with PA/QL can result in claim denial or member financial responsibility.

PA required for selected antifungals (e.g., CRESEMBA, posaconazole)

Certain antifungal agents (e.g., CRESEMBA, posaconazole) are listed with PA; claims for these products may be denied without an approved prior authorization — obtain PA and submit required clinical documentation prior to dispensing.

• CRESEMBA (isavuconazonium) — Coverage Requirements and Limits = PA.
• Posaconazole (susp and delayed release tabs) — Coverage Requirements and Limits = PA.

Obtain PA for PA‑designated drugs to avoid denial

Claims for medications listed with “PA” may be denied or require prior authorization review if an authorization is not obtained; verify PA requirements and obtain authorizations before dispensing these agents.

• Many oncology and specialty agents list PA — obtain authorization to prevent denial.
• PA absence on submission can trigger coverage denial.

PA required for oral oncology/specialty agents — risk of denial if not obtained

Failure to obtain prior authorization for oral oncology and many specialty agents marked PA may trigger coverage denial; submit PA requests with required supporting documentation to avoid claim denial.

• Oral oncology agents commonly show LD, OC, PA, QL — submit PA and use LD channels.
• Provide full clinical documentation to support medical necessity for PA.

Confirm PA presence — absence may cause claim denial

Lack of an approved prior authorization when PA is listed for an agent may trigger claim denial; confirm PA status and secure approvals before dispensing PA‑flagged medications.

• Verify PA prior to dispensing to avoid claim denial.
• Submit PA with indication and dosing details as required.

Coverage flags (PA/CW/IC/QL/ST/LD/SP) must be satisfied to avoid denial

Coverage codes and flags on drug lines (PA, CW, AC, IC, QL, ST, SP, LD) indicate programmatic controls; failure to meet any applicable control (for example not obtaining PA or exceeding QL) can trigger denial or member financial liability.

• PA — Prior Authorization required when shown.
• QL — Quantity Limit; exceeding QL may make member responsible for excess.
• IC/CW/LD/SP — State or distribution special handling that must be followed.

PA/CW designations for select GLP‑1/tirzepatide/glucagon products

Some GLP‑1 and tirzepatide products are designated PA or CW (e.g., MOUNJARO, OZEMPIC, TRULICITY); obtain PA where indicated and provide documentation for cost‑waived (CW) status when applicable to ensure coverage.

• MOUNJARO/OZEMPIC/TRULICITY show PA and product‑specific QL.
• Some glucagon/glucagon‑related products show CW — documentation may be needed for cost‑waived handling.

PA plus Limited Distribution — obtain PA and use LD channel

Products listed with both PA and LD flags require prior authorization and may need specific limited distribution arrangements; lacking either may prevent coverage or fulfillment — coordinate PA and required specialty channel routing.

• LD products (many oncology and some inhaled antibacterials) also list PA and QL.
• Work with specialty pharmacies or LD distributors as directed in product entries.