CurrentBlue Cross Blue Shield - IllinoisPolicy N/A

BCBSIL Prescription Drug List / Pharmacy Benefit Guide - Coverage Criteria

Governs the pharmacy drug list, tiering, coverage considerations, specialty drug services, and member/provider processes for Blue Cross Blue Shield of Illinois members and their prescribers.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyPrescription Drug List / Pharmacy Benefit Guide — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a medication is marked 'PA' before submitting a claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~90+drug entries in this excerpt

multipleentries with Prior Authorization (PA)

manyentries with Quantity Limits (QL)

Accredonamed specialty pharmacy

~120+drug and vaccine line items shown

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General Coverage Criteria

Covered when ALL of the following are met:

General coverage rules: Drugs shown on the drug list are covered according to the member's benefit plan; drugs not shown are not covered unless an exception is granted.

Most medications have special requirements noted in the Special Requirements column (e.g., PA, ST, QL, AC).

Supply limits: Standard coverage is up to a 30-day supply; maintenance medications may be covered up to 90 days per plan allowance.30 or 90 days

Some controlled substances and state laws may further limit covered quantities.

Exclusions and non-covered categories: Non–FDA-approved drugs, repackaged products, and certain compounded medications are not covered; some drugs with OTC equivalents may be excluded per plan.

Refer to member benefit materials for plan-specific exclusions.

Vaccine/biologic administrative coverage

Covered when ALL of the following are met:

Administrative coverage for vaccines/biologics: Many vaccine and other biologic products are listed with an administrative coverage indicator (AC); providers must follow payer administrative/authorization procedures when AC is shown.

Examples include multiple influenza, COVID‑19, hepatitis, pneumococcal and other vaccines marked 'AC'.

Oncology/specialty coverage controls

Covered when ALL of the following are met:

Oncology/specialty agent controls: Oral antineoplastic and other specialty oncology agents require prior authorization (PA) and have specified quantity limits (QL); many are designated specialty (SP) and must be routed through specialty distribution when indicated.

Examples: Zytiga (abiraterone) PA + QL + SP; many TKIs and targeted agents list PA, QL, and SP.

Product-level coverage controls

Coverage is conditioned on product-level utilization controls:

Per-product utilization controls: Each product listing includes a drug tier and may include one or more utilization controls such as Administrative Coverage (AC), Quantity Limit (QL), Prior Authorization (PA), or Step Therapy (ST); coverage is contingent on meeting those controls.

Examples: contraceptives commonly list AC + QL (28 tablets/21 days); some antidiabetic/GLP‑1 agents show PA + QL.

Formulary listing coverage indicators

Per-line formulary indicators (all must be reviewed for coverage determination):

Formulary listing elements: Each drug line includes: drug name, formulation/strength, drug tier (e.g., P, NP, NP+, P+) and Requirements/Limits flags (e.g., PA, QL, SP, AC).

The presence of a flag (PA/QL/ST/SP/AC) indicates additional coverage requirements; clinical PA criteria are not detailed in this excerpt.

Coverage with utilization management

Coverage with utilization management applies when the following conditions are met:

PA and QL enforcement: Many covered products require prior authorization and/or are subject to quantity limits as indicated beside each product; prescribers must obtain PA where shown and adhere to stated QL for claim adjudication.

Examples: TRIKAFTA requires PA and QL (56 packets/28 days); ENTYVIO PEN shows PA and QL (2 pens/28 days).

Specialty drug handling

Specialty distribution requirements:

Specialty (SP) handling: Products flagged 'SP' require specialty pharmacy distribution and may require prior authorization and documentation of medical necessity for coverage.

Multiple biologic and high‑cost agents carry SP flags and associated PA/QL requirements (see product lines).

Formulary coverage with per-product requirements

Covered when ALL of the following per-product conditions are satisfied:

Per-product requirement compliance: Each product's coverage is subject to the drug tier and any Requirements/Limits listed (PA, QL, ST, SP); providers must meet the listed conditions for coverage to apply.

Consult individual product entries for exact QL values, PA indication, and ST requirements (e.g., HORIZANT shows QL and ST; INGREZZA shows PA, QL, SP).

The drug list is governed by the member's benefit plan and coverage is tier- and plan-dependent. Drugs shown on the formulary are covered only in accordance with the member's plan rules and any special requirements noted on the product line (for example, PA, QL, ST, AC, or SP), and standard pharmacy coverage generally allows up to a 30‑day supply with some plans permitting up to a 90‑day supply for maintenance medications.

The document excerpts do not contain explicit blanket exclusion statements for the listed products; however, the policy notes that certain categories are commonly excluded from pharmacy coverage — specifically non‑FDA‑approved drugs, repackaged medications, some compounded medications, and prescription products with available OTC equivalents. Absence of a Requirements/Limits flag on a product line in these chunks does not necessarily indicate unrestricted coverage — product‑level flags (e.g., PA, AC, QL, SP, ST) shown next to entries define the applicable conditions for coverage under the member’s plan and must be followed.

Within these segments there are no explicit clinical exclusions stated for the individual listed products. Entries appear as formulary line items showing Drug Tier and any inline Requirements/Limits indicators (for example, AC, PA, QL, SP, or ST), which are the mechanisms used to manage coverage rather than discrete clinical exclusion statements.

The policy specifically identifies certain uses as outside pharmacy coverage when appropriate — for example, medications used solely for cosmetic purposes (the document cites hair‑growth agents such as Propecia as an example) may not be covered under the pharmacy benefit and thus are considered excluded for that purpose.

These excerpted chunks do not present a separate list labeled “Not Medically Necessary.” Instead, management of coverage and exceptions is achieved through tier placement and the requirement flags shown with each product; where an item would be considered not medically necessary for a given indication, that determination and any denial rationale would be handled through the plan’s prior authorization/exception process rather than a per‑product “Not Medically Necessary” listing in these segments.

No items in these chunks are explicitly labeled as “not medically necessary.” Coverage determination is controlled by tiering and the per‑line Requirements/Limits flags (for example, PA, QL, SP, AC, or ST), and where coverage is conditional providers must meet those requirements or submit an exception as described in plan materials.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization (PA) may be required for many medications listed in this Drug List. When PA is commonly required it is noted in the Special Requirements/Requirements/Limits column next to the product (e.g., PA, PA, QL, SP). Providers must submit a prior authorization request and receive approval before the plan will cover the medication. Failure to obtain required PA may result in claim denial or delay of coverage.

PA is commonly required for specialty and oncology agents (examples: EPCLUSA, MAVYRET, SOVALDI, TRIKAFTA, many oral antineoplastics).
PA may be paired with Quantity Limits (QL) and Specialty handling (SP) — verify all three when present.
Authorization indicators in the product list: AC (access code), PA (prior authorization), ST (step therapy), QL (quantity limit), SP (specialty).

Prior Authorization

PA for Specialty / Oncology Drugs

Certain specialty, oncology, and other high-cost agents require PA and often specialty pharmacy dispensing. These products are specifically flagged in the Requirements/Limits column (e.g., PA, QL, SP). Examples across the Drug List include many targeted oral oncology agents, biologics, and specialty infusion or injectable therapies.

Examples: abiraterone (Zytiga) — PA, QL, SP; ALECENSA, ALUNBRIG, BOSULIF, BRUKINSA, CABOMETYX — PA, QL, SP; IBRANCE, VENCLEXTA, VERZENIO — PA, QL, SP.
Cystic fibrosis modulator TRIKAFTA is listed with PA, QL, SP.
Many specialty biologics (e.g., NUCALA, FASENRA, Omalizumab/XOLAIR equivalents) have PA and QL requirements.

Prior Authorization

Prior Authorization for Selected Specialty Drugs

Selected specialty drugs across categories are designated as PA and SP and/or have QL. Providers should expect to provide clinical documentation (diagnosis, prior therapies, dosing schedule, relevant labs) to support medical necessity when requesting PA.

Examples: MOUNJARO and OZEMPIC (GLP‑1/diabetes/weight‑management agents) have PA and QL controls.
Examples: PROCYSBI and VANRAFIA require PA and specialty handling.
Many rare disease and enzyme-replacement therapies require PA and specialty enrollment.

Denial Risk

Authorization Indicators and Denial Risk

When a PA or other authorization indicator (AC, ST, QL, SP) is present, follow the indicated utilization program before coverage is approved. Requests submitted without the required authorization are at risk for denial; the product list flags these requirements to reduce denial risk.

Authorization indicators you will see in the list: AC (access/preauthorization code), PA (prior authorization required), ST (step therapy), QL (quantity limits), SP (specialty handling).
If an item is flagged PA (with or without QL/SP), do not assume automatic coverage — submit PA prior to dispensing.
Denial risk: claims processed without required PA or exceeding QL may be denied or subject to member financial responsibility.

Denial Risk

Quantity Limits and Exceedance Risk

Quantity limits (QL) are applied to many products to encourage appropriate use and align with FDA dosing. Prescriptions that exceed the stated QL may be denied or result in reduced coverage; providers should document medical necessity if a higher quantity is clinically indicated.

Examples: GLYXAMBI and many GLP‑1/diabetes agents have explicit QL values listed (e.g., 30 tablets/30 days).
Exceeding QL: prescribers should provide supporting documentation describing expected duration and dose if prescribing quantities above the QL.
QL often accompanies PA and SP for specialty therapies — check all three fields in Requirements/Limits.

Step Therapy

Step Therapy Requirements

Step Therapy (ST) may be required for certain therapeutic classes. When ST is applicable it is indicated with an "ST" in the Special Requirements/Requirements/Limits column. Providers must follow the plan's step edits (try specified first-line agents) or submit a step‑therapy exception to obtain coverage for the non-preferred therapy.

ST applies to select CNS, antipsychotic, gabapentin, hypnotic, and other agents (examples flagged in the Drug List).
Possible step edits: products marked SP may also be subject to step edits in some benefit designs; check member plan materials.
Access codes and utilization program codes (AC) may be required in conjunction with ST for some contraceptive and preventive products.

Documentation Required

Documentation and Specialty Pharmacy Requirements

Documentation requirements: For any PA, QL, ST, or SP request, submit clinical documentation to support medical necessity. This typically includes diagnosis, prior therapy history, dosing regimen, relevant laboratory or genetic testing (when applicable), and anticipated duration of therapy. Specialty drugs also typically require enrollment in a specialty pharmacy.

PA documentation: diagnosis, prior treatments tried and failed or contraindicated, labs or genetic test results if required.
QL documentation: rationale for requested quantity and expected duration of use (e.g., SOMAVERT dosing justification).
Specialty pharmacy: enroll members in the designated specialty pharmacy when SP is indicated and provide any required specialty dispensing forms.

Note

Exception Requests, Timelines, and Denial Notification

Exception and expedited review process: The member, prescriber, or authorized representative may request a Drug List exception or expedited review when medically necessary. Standard exception decisions will be provided within 15 calendar days; expedited requests for cases where life, health or function are at risk will be decided within 72 hours. If an exception or PA request is denied, BCBSIL will notify the member and prescriber with reasons and, when applicable, offer a covered alternative drug.

To request an exception or copay waiver, call the number on the member ID card or follow the instructions in the member's plan materials.
Denial communication will include rationale and, when available, an offer of an appropriate covered alternative.
Expedited reviews: submit clinical justification showing imminent risk to life, health, or ability to function to request faster turnaround (72 hours).

Terminology and Abbreviations

Specialty drugs definition and characteristics

Specialty drugs definitionMedications for complex conditions that may be oral, topical, or injectable and can be self‑administered or administered by a health care professional; specialty list available at MyPrime.com or bcbsil.com

CharacteristicsOften high-cost, may require specialty distribution (SP), prior authorization (PA), and quantity limits (QL)

Site-of-care implicationMedications administered by a health care professional are not covered under the pharmacy benefit and may be covered under the medical benefit

Generic equivalent vs generic alternative

Generic equivalentSame active ingredient(s) at the same dosage as the reference brand (chemically the same and meets FDA standards)

Generic alternativeUsed to treat the same condition but contains different active ingredient(s) than the brand drug

Member payment noteMember may owe the difference in cost if choosing the brand over a generic equivalent

PA definition

DefinitionPrior Authorization (PA) — coverage requires approval from the plan before the drug is dispensed (noted as 'PA' in Requirements/Limits)

Provider actionPrescribers should submit documentation supporting PA requests where PA is listed

Denial riskRequests may be denied if PA is not obtained for drugs listed with 'PA'

QL definition

DefinitionQuantity Limit (QL) — a specified maximum quantity for a defined time period (e.g., QL (30 tablets/30 days), QL (60 capsules/30 days))

Claim requirementsPharmacy claims should reflect NDC/formulation and dispensed quantity consistent with the stated QL

Exceeding QLExceeding the QL may result in denial or responsibility for full cost beyond coverage limits

SP definition

DefinitionSP = Specialty Pharmacy — product designated for specialty distribution and often requires enrollment in specialty channel

HandlingProducts flagged 'SP' may require specialty pharmacy dispensing and additional documentation for coverage

Site-of-careSpecialty products may be routed via infusion center or specialty pharmacy depending on administration

QL — quantity limit definition example

Example QL statementQuantity Limit — the maximum units allowed within the specified time frame (e.g., QL (120 capsules/30 days))

PurposeDispensing limits encourage medication use as intended by FDA and are noted with 'QL' in Requirements/Limits

Provider actionIf greater quantity is needed prescriber may request PA or exception; member may pay full cost for excess

AC definition (Authorization Code / Administrative Coverage)

AC definitionAC = Authorization Code / Administrative Coverage — appears next to many vaccines and biologics indicating an administrative coverage requirement

VaccinesMany vaccine entries show Requirements/Limits = AC (administrative coverage)

Follow processProviders should follow payer AC process for listed vaccines/biologics

PA = Prior Authorization (short)

PA (short)PA = Prior Authorization

Noted locationShown in the Requirements/Limits column next to product entries when required

ConsequenceCoverage may be denied without PA when listed

QL = Quantity Limit (short)

QL (short)QL = Quantity Limit (specified as count per time period, e.g., 30 tablets/30 days)

ExamplesUsed widely across products (tablets, capsules, mL, pens, syringes)

ImpactClaims exceeding QL may be denied or require PA/exception

SP = Specialty Pharmacy (short)

SP (short)SP = Specialty Pharmacy

ImplicationIndicates dispensing via specialty channel and may require SP enrollment

DocumentationSpecialty drugs often require PA and additional documentation

AC definition (later segment)

AC (later segment)AC denotes administrative coverage/access code used in Requirements/Limits (commonly for contraceptives and vaccines)

Contraceptive examplesMany contraceptives show AC and QL (28 tablets/21 days) or AC with ring QL (1 ring/21 days)

Follow planOperational meaning/processing per plan utilization management programs

PA (repeated)

PA (repeated definition)Prior Authorization indicates pre-approval required for coverage and is noted with 'PA' next to products

Specialty oncologyMany oral oncology agents require PA as indicated

Provider actionObtain PA before claim adjudication where listed

QL (repeated)

QL (repeated)Quantity Limit — maximum units allowed in specified time (e.g., tablets/30 days; mL/30 days)

ExamplesMultiple per-line QLs (e.g., 56 packets/28 days, 60 tablets/30 days, 900 mL/30 days)

EnforcementPrescriptions must adhere to stated QL; documentation for exceptions required

ST definition (step therapy)

ST definitionST = Step Therapy — requires trial/failure of preferred agent(s) prior to coverage for the listed product

NotationIf step therapy applies it is noted with 'ST' in the Special Requirements column

ExamplesST applies to several CNS/antipsychotic agents (e.g., AUVELITY, FETZIMA, TRINTELLIX, some aripiprazole/clozapine lines)

Step Therapy Requirements

Coverage note
If step therapy applies it will be noted with "ST" in the Special Requirements column (see Step Therapy description).

Agent / Example	Notes
Abiraterone (Zytiga)
Many agents marked 'SP' denote specialty benefit tiering; specialty products typically require prior authorization before dispensing and may have QL noted.

Agent / Example	Requirements
CALQUENCE (acalabrutinib) and other oral oncology agents
Require prior authorization (PA) and often have quantity limits (QL) and specialty (SP) designation as listed; PA must be obtained before coverage.

Product group	Special Requirements
Contraceptives (e.g., desogestrel/ethinyl estradiol, drospirenone-containing products, NUVARING, ELLA)
Many contraceptives are listed with 'AC' (administrative/authorization code) or 'PA' and include QL (e.g., 28 tablets/21 days); follow the indicated access/authorization process.

Agent / Example	Utilization controls
MOUNJARO (tirzepatide) and GLP-1 agents (e.g., OZEMPIC, WEGOVY, semaglutide products)
Managed with prior authorization (PA) and quantity limits (QL) as specified (e.g., MOUNJARO: PA, QL 4 pens/28 days); explicit step therapy sequences are not listed in the excerpts.

Agent	Controls
ORILISSA (elagolix / related entries) and similar agents
Listed with prior authorization (PA) and quantity limits (e.g., ORILISSA QL 30 or 60 tablets/30 days); no explicit prior step is specified in the provided chunks.

Agent group	Management
High-cost specialty agents (examples: REPATHA, CAMZYOS, WINREVAIR, VYNDAQEL)
Managed with prior authorization (PA) and quantity limits (QL); many are designated specialty (SP). Step therapy specifics are not detailed in these segments.

Observation	Implication
Document segments show tiering and utilization flags (PA, QL, SP) for many products
No explicit step therapy sequences are provided in these excerpts; apply the shown tiering and PA/QL/SP controls per product line.

Program code	Action required
AC (Administrative Coverage / Authorization Code)
Follow specified utilization management program codes (e.g., AC) prior to coverage for products that list AC in Requirements/Limits (examples include bowel preps and some contraceptives).

Agent examples	Step therapy status
AUVELITY (dextromethorphan-bupropion), FETZIMA (levomilnacipran), FLUOXETINE DR, TRINTELLIX (vortioxetine), various aripiprazole formulations, clozapine ODT, risperidone ODT
Marked 'ST' — step therapy is required prior to coverage for these CNS and antipsychotic agents as indicated in the Requirements/Limits entries.

Entry / Example	ST flag meaning
VERSACLOZ (clozapine suspension), Gralise (gabapentin once-daily), HORIZANT (gabapentin enacarbil)
Entries marked 'ST' indicate step therapy applies and must be completed prior to coverage (HORIZANT explicitly shows 'ST').

Product	Step therapy status
HORIZANT (gabapentin enacarbil)
Requirements/Limits = QL (60 tablets/30 days), ST — indicates a step therapy requirement applies to HORIZANT.

Quantity Limits and Dispensing Maximums

Plan-specified quantity limits (applies where QL noted)

Plan-specified QLsPlan-specified quantity limits apply where 'QL' is noted for a product; visit plan resources for full list

Source guidanceFor a list of medications and their dispensing limits visit MyPrime.com or bcbsil.com

ApplicabilityApplies across many therapeutic classes as shown in per-line QL entries

EPCLUSA sofosbuvir-velpatasvir tab — 30 tablets/30 days

EPCLUSA (sofosbuvir-velpatasvir)QL (30 tablets/30 days)

PA noteEPCLUSA listed with PA in Requirements/Limits

SpecialtyEntry indicates SP in some presentations

MAVYRET glecaprevir-pibrentasvir tab — 90 tablets/30 days

MAVYRET (glecaprevir-pibrentasvir)Requirements/Limits = PA, QL (90 tablets/30 days)

SpecialtySome presentations denoted SP

Provider actionPA required before coverage where listed

XIFAXAN rifaximin tab 550 mg — 60 tablets/30 days

XIFAXAN rifaximin 550 mgQL (60 tablets/30 days)

XIFAXAN rifaximin 200 mgQL (9 tablets/30 days)

TieringXIFAXAN 550 mg listed Drug Tier = P

SIVEXTRO (tedizolid phosphate tab 200 mg) — 6 tablets

SIVEXTRO (tedizolid 200 mg)QL (6 tablets/180 days)

Therapeutic classOral anti-infective — dispensing limit applied to limit total tablets over 180-day period

Provider noteAdhere to QL when submitting pharmacy claim

Vancocin (vancomycin capsules) — 120 capsules

Vancocin (vancomycin HCl capsules)QL (120 capsules/30 days)

Formulation noteCapsule strengths listed; large QL reflects oral vancomycin for specific indications

Claim documentationPharmacy claims should reflect NDC and dispensed quantity consistent with QL

XIFAXAN 200 mg — 9 tablets

XIFAXAN 200 mgQL (9 tablets/30 days)

Use caseSmaller tablet QL often reflects specific short-course indications

ClaimsAdhere to QL when billing; exceptions require justification

XIFAXAN 550 mg — 60 tablets

XIFAXAN 550 mgQL (60 tablets/30 days)

Indication noteHigher QL aligned with chronic/maintenance dosing in some indications

TieringListed with Drug Tier = P in some presentations

Various oncology agents — assorted QLs (examples consolidated)

Oncology agents (assorted QLs)Examples include QL (120 tablets/30 days), QL (240 capsules/30 days), QL (90 tablets/30 days), QL (60 tablets/30 days)

PA and SPMany antineoplastics include PA and SP in Requirements/Limits

Provider actionObtain PA and document diagnosis/dosing when requesting quantities at or above QL

acalabrutinib — 60 tablets

acalabrutinib (CALQUENCE)QL (60 tablets/30 days)

Specialty noteCALQUENCE entries include PA and SP designations

Provider noteQuantity limit consistent with daily dosing regimens

dasatinib 20 mg — 90 tablets

dasatinib 20 mg (Sprycel)QL (90 tablets/30 days) for 20 mg strength (other strengths have per-line QLs)

PA/SPPA and SP indicated for many dasatinib presentations

Dose packsLarger QLs reflect multi-strength pack dosing for oncology regimens

rucaparib — 120 tablets

rucaparib (RUBRACA)QL (120 tablets/30 days)

PA and SPEntry lists PA and SP in Requirements/Limits for many strengths

Provider actionAdhere to QL or obtain PA for higher quantities

RETEVMO — 60 tablets

RETEVMO (selpercatinib)QL (60 tablets/30 days)

PA/SPListed with PA and SP in Requirements/Limits

Dosing contextQL aligns with expected chronic daily dosing

REVUFORJ 25 mg — 240 tablets

REVUFORJ (revumenib) 25 mgQL (240 tablets/30 days)

PA/SPRequirements/Limits include PA and SP for many presentations

High QL noteLarge tablet QL reflects specific dosing schedules used clinically

VITRAKVI oral solution — 300 mls

VITRAKVI oral solutionQL (300 mL/30 days)

PA/SPPA and SP are noted for some VITRAKVI presentations

Solution formulationQuantity limit expressed in mL for oral solution form

ANNOVERA — 1 ring

ANNOVERA vaginal ringQL (1 ring/365 days)

Contraceptive accessANNOVERA listed with QL specifying one ring per year

AC/QL patternsContraceptive products often show AC plus QL (28 tablets/21 days) or ring QL measures

Testosterone TD gel 50 mg — 300 grams

Testosterone TD gel 50 mgRequirements/Limits = PA, QL (300 grams/30 days)

Other testosterone formsOther topical/solution presentations have differing QLs (e.g., 150 g/30 days; 180 mL/30 days)

Provider documentationPA and QL require supporting documentation for medical necessity

OpenPayer

BCBSIL Prescription Drug List / Pharmacy Benefit Guide - Coverage Criteria

Coverage Criteria and Formulary Controls

Drug Entries and Code Tables

Provider Requirements, Prior Authorization, and Documentation

Policy Background and Scope

Terminology and Abbreviations

Initial Therapy and Initiation Controls

Step Therapy Requirements

Quantity Limits and Dispensing Maximums

Site of Care and Specialty Distribution