CurrentBlue Cross Blue Shield - IllinoisPolicy N/A

2025 Drug List (Therapeutic Class Drug List) - Blue Cross Blue Shield of Illinois

This document is the BCBSIL 2025 Drug List describing covered pharmacy drugs, tier placement, special requirements (PA, ST, QL, SP, AC), dispensing/quantity limits, specialty pharmacy referral (Accredo), exception and expedited review processes, and member/provider guidance for drug coverage and use.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

Policy2025 Drug List (Therapeutic Class Drug List) - Blue Cross Blue Shield of Illinois

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit a prior authorization request when a medication is listed with 'PA' under Special Requirements; approval is required before coverage if PA applies.

POLICY UPDATE CHANGES

No material clinical or coverage changes (has_material_change = false).

100+Drugs listed in this part

ManyEntries with QL

MultipleEntries requiring PA or SP

1Specialty pharmacy vendor (Accredo)

Coverage Summary & Scope

Coverage / Special Requirements

Coverage / Special Requirements: The following criteria summarize how the formulary uses special requirement flags and the general coverage statement applied to drugs on the BCBSIL Drug List.

ALL of the following

General coverage statement: Drugs shown on the Drug List are eligible for coverage under the pharmacy benefit when the member has pharmacy coverage and the drug is included in the member’s specific benefit plan. Drugs not shown on the list are not covered through the pharmacy benefit unless otherwise specified in plan materials or approved via exception/medical benefit.
Prior Authorization (PA): A PA flag indicates that a clinical review is required before the plan will cover the drug. The prescriber must submit the required clinical information and supporting documentation. Coverage is approved only when the clinical criteria are met and the PA is granted. Some plans may require PA for additional drugs beyond those flagged in this document; refer to the member’s benefit plan for specifics.
Prior authorization requests should include relevant diagnoses, previous therapies tried, and supporting clinical documentation to avoid delay.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

Policy2025 Drug List (Therapeutic Class Drug List) - Blue Cross Blue Shield of Illinois

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit a prior authorization request when a medication is listed with 'PA' under Special Requirements; approval is required before coverage if PA applies.

On This Page

Requirements / Limits entries

Requirements / Limits entries: the table below defines the operational meaning of flags or a blank entry in the Special Requirements column on the Drug List.

{"text":"PA — Prior Authorization required: Coverage requires an approved prior authorization request submitted to the plan. The request must include clinical documentation supporting FDA‑approved or accepted off‑label use consistent with plan criteria.","note":"If PA is not obtained, the claim may be denied or the member may be held financially responsible."},{"text":"ST — Step Therapy required: Coverage requires documented trials of specified alternative(s) prior to coverage of the requested product. Prior therapy documentation or an approved exception is required for coverage.","note":"Step therapy may be bypassed with documentation of contraindication or intolerance to the required agent(s)."},{"text":"QL — Quantity Limit / Dispensing Limit applies: Coverage is limited to a defined maximum quantity or days’ supply within a specified time frame. Additional quantity requires prior authorization or may be denied.","note":"Common limits include maximum units per 30 days, per prescription, or per calendar year."},{"text":"SP — Specialty drug: Medication designated as specialty requires dispensing through the plan’s specialty pharmacy vendor (Accredo) and may include special handling, onboarding, and care‑management requirements.","note":"Prior authorization and benefit verification commonly required for specialty agents."},{"text":"AC — Medical Benefit / Administration code: The product is typically billed to the medical benefit using administration/HCPCS codes rather than through the pharmacy point-of-sale. Coverage rules and prior authorization requirements under the medical benefit may differ.","note":"Providers should verify benefit and billing pathway prior to ordering."},{"text":" — No special requirement flagged: Drug is listed on the formulary without a PA, ST, QL, SP, or AC flag. Coverage remains subject to member’s specific benefit design (tier, quantity limits that are plan-level, and exclusions).","note":"Absence of a flag does not guarantee coverage for every plan; confirm the member’s benefit details."}

Formulary Entries & Code Groups (sample)

Anti-infective — Sample Drug ListmixedCovered

AMOXICILLIN	amoxicillin (various strengths/forms)
AMOXICILLIN & K CLAVULANATE	amoxicillin/clavulanate (Augmentin formulations)
AUGMENTIN	AUGMENTIN (brand)
AUGMENTIN ES-600	AUGMENTIN ES-600 suspension
PENICILLIN V POTASSIUM	penicillin V potassium
CEFACLOR	cefaclor
CEFADROXIL	cephadroxil
CEPHALEXIN	cephalexin
AZITHROMYCIN	azithromycin (tablets, suspensions)
CLARITHROMYCIN	clarithromycin (including ER 500 mg)

1–10 of 49

1/5

Antiviral & HIV/HCV — Sample Drug ListmixedCovered

APRETUDE	APRETUDE (cabotegravir extended-release 600 mg/3 mL)
APRETUDE cabotegravir im extended release susp 600 mg/3ml	APRETUDE 600 mg/3 mL
BIKTARVY	BIKTARVY (bictegravir-emtricitabine-tenofovir alafenamide) various strengths
Biktarvy	Biktarvy (alternate casing)
CIMDUO	CIMDUO (lamivudine-tenofovir disoproxil fumarate 300-300 mg)
CIMDUO lamivudine-tenofovir disoproxil fumarate tab 300-300 mg	CIMDUO 300-300 mg
abacavir solutions	abacavir oral solution
abacavir tabs	abacavir tablets
abacavir sulfate-lamivudine 600-300 mg (Epzicom)	Epzicom 600-300 mg
abacavir sulfate (Ziagen)	Ziagen

1–10 of 63

1/7

Antifungal & Mycobacterial — Sample Drug ListmixedCovered

SIRTURO	SIRTURO (bedaquiline)
SIRTURO (repeat)	listed earlier
BAXDELA	BAXDELA (also antibacterial)
CRESEMBA	CRESEMBA (isavuconazole)
NOXAFIL	NOXAFIL (posaconazole)
VORICONAZOLE	voriconazole
VIVJOA	VIVJOA (lefamulin)

Antimycobacterial/NTM Inhaled — Sample Drug ListmixedCovered

ARIKAYCE	ARIKAYCE (amikacin liposomal inhalation)
TOBI PODHALER	TOBI PODHALER
TOBRAMYCIN (nebu soln)	nebulized tobramycin

Antibacterials — Prior Authorization Entriesmixed

NUZYRA	NUZYRA — PA may be required per plan
BAXDELA	BAXDELA — PA may be required
DIFICID	DIFICID — PA may be required

Antivirals — Prior Authorization Entriesmixed

APRETUDE	APRETUDE — PA typically required
PAXLOVID	PAXLOVID — plan-specified requirements
LIVTENCITY	LIVTENCITY — PA may be required

HIV/HCV — Formulary, Tiers & NotationsmixedCovered

BIKTARVY	Preferred (tiering depends on member plan) — may have step/PA
TRIUMEQ	Formulary listing — pediatric suspension noted
DESCOVY	Multiple strengths listed
Genvoya/Stribild	Listed — various formulations
COMPLERA	Listed — multiple strengths
MAVYRET	Listed — preferred HCV DAA option in many plans

Antimalarials & ParasiticidesmixedCovered

CHLOROQUINE PHOSPHATE	chloroquine phosphate 250 mg and 500 mg
hydroxychloroquine sulfate	hydroxychloroquine (various strengths)
COARTEM	COARTEM (artemether-lumefantrine)
KRINTAFEL	KRINTAFEL (tafenoquine) 150 mg
mefloquine hcl tab 250 mg	mefloquine 250 mg
primaquine phosphate tab 26.3 mg	primaquine 26.3 mg (15 mg base)
pyrimethamine tab 25 mg (Daraprim)	pyrimethamine 25 mg
quinine sulfate cap 324 mg (Qualaquin)	quinine sulfate 324 mg

Misc Anti-infective Agents & GI AgentsmixedCovered

metronidazole	metronidazole (various forms)
tinidazole	tinidazole (where applicable)
vancomycin oral	vancomycin oral formulations
XIFAXAN 550 mg	rifaximin 550 mg
SOLOSEC	secnidazole 2 g granules
florok etc	other misc GI anti-infectives

Vaccines, Biologics & Immunotherapies — Sample ListmixedCovered

Biologicals and Vaccines	Many specific vaccine products (ADACEL, BOOSTRIX, DAPTACEL, INFANRIX, KINRIX, PEDIARIX, PENTACEL, QUADRACEL, TENIVAC, VAXELIS, etc.)
PALFORZIA	PALFORZIA peanut oral immunotherapy levels and packs
GRASTEK/ODACTRA/ORALAIR	allergen SL tablets listed

Antifungals & Systemic Antimycotics — Prior Authorization / QLmixed

CRESEMBA	CRESEMBA — may have PA/QL
NOXAFIL	NOXAFIL — may have PA/QL
VORICONAZOLE	voriconazole — plan requirements may apply

Large Specialty & Hepatic/Antiviral — Sample EntriesmixedCovered

HARVONI pellet pack	HARVONI pellet pack strengths listed
EPCLUSA pellet pack	EPCLUSA pellet pack strengths listed
SOVALDI pellet pack	SOVALDI pellet pack strengths listed
VOSEVI	VOSEVI listed

Antiretrovirals — Pediatric & FormulationsmixedCovered

lamivudine oral soln 10 mg/ml (Epivir)	Epivir oral solution
lamivudine tab 150 mg; 300 mg (Epivir)	lamivudine tablet strengths
EMTRIVA emtricitabine soln 10 mg/ml	emtricitabine solution
abacavir oral susp	abacavir suspension

Antimicrobial Stewardship — Quantity Limits (QL) Examplesmixed

azithromycin tab	may have QL per plan (typical 5-day course limits)
clarithromycin ER 500 mg	QL may apply
nuzyra 150 mg	QL or PA may apply
baxdela 450 mg	QL or PA may apply

OpenPayer

2025 Drug List (Therapeutic Class Drug List) - Blue Cross Blue Shield of Illinois

Coverage Summary & Scope

Actions for Providers — Prior Auth, Specialty Routing, Exceptions

Formulary Entries & Code Groups (sample)