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Prescription Drug Information

Prescription drugs are an important part of your health care coverage. If you have prescription drug coverage through Blue Cross and Blue Shield of Illinois (BCBSIL), we want to help you better understand your prescription drug coverage and options, including convenient services and any limitations. Here you'll find helpful information and forms you need.

This is only a brief description of some of the prescription drug benefits. Not all benefits are offered by all health plans. For more complete details, including benefits, limitations and exclusions, please refer to your benefit materials.

Drug Lists (Formularies) for Metallic Individual Plans

The drug lists, also known as a formulary, below are used with your health plan if all of these apply to you:

  • You enrolled in a plan on your own (instead of through your employer) and
  • Your plan is a "metallic" health plan, which can include a Platinum, Gold, Silver, Bronze, Multi-State or Catastrophic plan.

Your prescription drug benefits through BCBSIL may be based on one of two different drug lists:

  • A Standard Drug List is a list of preferred drugs which are considered to be safe and cost-effective.
  • A Generics Plus Drug List is a smaller version of the Standard Drug List. It covers drugs for the major drug classes, but includes mostly generic drugs and fewer brand-name drugs.

These prescription drug lists have different levels of coverage, which are called "tiers." Generally, how much you pay out of pocket for a prescription drug will be less if you choose a drug that is a lower tier.

These drug lists are effective January 1, 2015:

These drugs lists were effective January 1, 2014 (Coverage ends December 31, 2014, with the exception of a plan with an off-cycle 2015 renewal date. Check your benefit materials for details.):

Want to know which drug list (formulary) your Marketplace plan uses? Check the charts below.

Drugs Lists (Formularies) for Grandfathered Individual Plans

The drug lists, or formularies, below are used with your health plan if all of these apply to you:

  • You enrolled in a plan on your own (instead of through your employer),
  • Your current BCBSIL policy was effective before January 1, 2014, and
  • Your plan is not a "metallic" health plan.

Your prescription drug benefits through BCBSIL may be based on one of two different or drug lists:

  • A Standard Drug List is a list of preferred drugs which are considered to be safe and cost-effective.
  • A Generics Plus Drug List is a smaller version of the Standard Drug List. It covers drugs for the major drug classes, but includes mostly generic drugs and fewer brand-name drugs.

These prescription drug lists have different levels of coverage, which are called "tiers." Generally, how much you pay out of pocket for a prescription drug will be less if you choose a drug that is a lower tier.

These updated drug lists apply starting January 1, 2015:

These updated drugs lists applied as of January 1, 2014:

Drug Lists (Formularies) for Employer-offered Plans: Large Group (51 or more employees)

The drug lists, or formularies, below are used for BCBSIL health plans that are offered through your employer. If your company has 51 or more employees, your prescription drug benefits through BCBSIL may be based on the Standard Drug List or the Generics Plus Drug List. The Generics Plus Drug List is a smaller version of the Standard Drug List. It includes mostly generic drugs and fewer brand-name drugs. The Generics Plus Drug List covers drugs for the major drug classes. Within a drug list, generally the lower the tier, the lower the cost of the drug.

These drug lists are effective starting January 1, 2015:

These drug lists were effective January 1, 2014.

Drug Lists (Formularies) for Employer-offered Metallic Plans: Small Group (1–50 employees)

The drug lists, also known as a formulary, below are used with BCBSIL "metallic" health plans that are offered through your employer. These can include Platinum, Gold, Silver, or Bronze plans.

If your company has 1–50 employees, your prescription drug benefits through BCBSIL may be based on a Standard Drug List or a Generics Plus Drug List. The Generics Plus Drug List is a smaller version of the Standard Drug List. It includes mostly generic drugs and fewer brand-name drugs. The Generics Plus Drug List covers drugs for the major drug classes. These prescription drug lists have different levels of coverage, which are called "tiers." Within a drug list, generally the lower the tier, the lower the cost of the drug.

These drug lists are effective January 1, 2015:

These drugs lists were effective January 1, 2014 (Coverage ends December 31, 2014, with the exception of a plan with an off-cycle 2015 renewal date. Check your benefit materials for details.):

Want to know which drug list (formulary) your Illinois Health Insurance Marketplace plan uses?

Drug Lists (Formularies) for Employer-offered Non-Metallic Plans: Small Group (1–50 employees)

The drug lists, or formularies, below are used for BCBSIL health plans that are offered through your employer. These health plans are not a "metallic" health plan and were effective before January 1, 2014.

If your company has 1–50 employees, your prescription drug benefits through BCBSIL may be based on a Standard Drug List or a Generics Plus Drug List. The Generics Plus Drug List is a smaller version of the Standard Drug List. It includes mostly generic drugs and fewer brand-name drugs. The Generics Plus Drug List covers drugs for the major drug classes. These prescription drug drug lists have different levels of coverage, which are called "tiers." Within a drug list, generally the lower the tier, the lower the cost of the drug.

These updated drug lists apply starting January 1, 2015:

These updated drugs lists applied as of January 1, 2014:

What You Should Know about the Prescription Drug Formulary

A formulary is a list of preferred drugs that are available to BCBSIL members. These drugs are considered to be safe and cost-effective. How much you pay out-of-pocket for prescription drugs is determined by whether your medication is on the list. Within a formulary, generally the lower the tier, the lower the cost of the drug. Generic drugs usually cost less than brand-name drugs, and this saves money.

No matter which formulary you use with your health plan (individual or group), here are some helpful tips:

  • Please talk with your doctor about prescribing drugs on the formulary. This may help reduce your out-of-pocket costs.
  • The list may help guide you and your doctor in choosing a drug that will work best for you.
  • View the Commonly Prescribed Standard Formulary Medications list . These are drugs taken regularly for an ongoing condition.
  • Note that some medication classes (for example, fertility) may be excluded by some plans. This means they are not covered. See your benefit materials for details.

Search Formulary and Find a Pharmacy

If your health plan includes BCBSIL prescription drug benefits, these are administered by Prime Therapeutics, the pharmacy benefit manager (PBM).

Visit Prime Therapeutics  to:

  • Search for prescription drugs
  • Find a pharmacy
  • Order mail service refills or new prescriptions online
  • View status of coverage for your drugs
  • Download forms and brochures
  • Get drug cost estimates
  • Learn more about drug side effects or interactions

BCBSIL has a broad network of contracting pharmacies. To use your benefits, simply find a contracting pharmacy close to you and present your member ID card.

What You Should Know About Dispensing Limits

  • Your prescription drug coverage includes limits on certain medications.
  • Limits may include quantity of covered medication per prescription, quantity of covered medication in a given time period and coverage only for members within a certain age range.
  • These limits reflect generally accepted pharmaceutical manufacturers' guidelines.
  • They also help encourage medication use as intended by the U.S. Food and Drug Administration (FDA).
  • For more information, view the Standard Drug List Dispensing Limits  and Generics Plus Drug List Dispensing Limits .

Over-the-Counter Equivalent Exclusion Program

Medications with an equivalent available over-the-counter (OTC) are usually not covered through Blue Cross and Blue Shield of Illinois 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 on the back of your ID card.
  • Talk with your doctor before making any changes to your current medication regimen. As always, treatment decisions are between you and you doctor.

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

Mail Service Program

PrimeMail®, the mail service pharmacy for members with BCBSIL prescription drug coverage, provides safe, fast and cost-effective pharmacy services that can save you time and money. With this program, you can obtain up to a 90-day supply of long-term (or maintenance) medications through PrimeMail. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes. View the maintenance drug list  to see if your medication is included.

Ordering Through PrimeMail

When you log in to Blue Access for Members and visit your Rx Drugs page, you can use the online order form, print an order form to mail or ask that PrimeMail get in touch with your doctor to request a new prescription.

For more information about using mail service:

  • Download the PrimeMail flier .

  • Call the Pharmacy Program number on the back of your ID card

Prime Specialty Pharmacy

Your prescription drug benefit may include a specialty pharmacy program through Prime Therapeutics Specialty Pharmacy (Prime Specialty Pharmacy).

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis. These drugs are typically given by injection, but may be topical or taken by mouth. They often require careful adherence to treatment plans, have special handling or storage requirements, and may not be stocked by retail pharmacies.

View the Specialty Pharmacy Program Drug List  which includes a reminder about coverage for self-administered specialty medications.


When you purchase specialty medications through Prime Specialty Pharmacy, you can have your self-administered specialty medications delivered directly to you, or to your doctor's office. You also receive at no additional charge:

  • Support services for managing your drug therapy
  • Educational materials about your particular condition
  • Help with managing potential medication side effects
  • 24/7/365 customer service phone access

Note: Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Prior Authorization/Step Therapy Program

The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use.


This program may be part of your prescription drug benefit plan. To find out if your specific benefit plan includes the prior authorization/step therapy program, and which drugs are part of your plan, refer to your plan materials, or call the Pharmacy Program number on the back of your ID card.


Prior Authorization

Under this part of the program, your physician will be required to obtain authorization through Blue Cross and Blue Shield of Illinois in order for you to receive benefits for certain medications and drug categories.

  • Examples of drug categories and specific medications for which a prior authorization program may be included as part of your prescription drug benefit plan are listed below.
  • Please note that drug categories may be added and the medications listed are only examples. Call the Pharmacy Program number on the back of your ID card with questions about a specific medication.
  • As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
Drug CategoryPrescription Drugs within the Category*

Prior Authorization

Acne Topical (Retinoids)

Atralin, Avita, Differin, Epiduo, Fabior, Retin-A, Retin-A Micro, Tazorac, Tretin-X, Veltin, Ziana

Androgens/Anabolic Steroids

Anadrol-50, Androderm, Androgel, Android, Androxy, Axiron, danazol, Delatestryl, Depo-Testosterone, First-Testosterone, Fortesta, Methitest, Oxandrin, Striant, Testim, Testred, Vogelxo

Antifungal Agents

Noxafil, Vfend

Attention Deficit Hyperactivitiy Disorder (ADHD)

Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Dexedrine, dextroamphetamine, Focalin, Focalin XR, Intuniv, Kapvay, Metadate CD, Metadate ER, Methylin, Procentra, Quillivant XR, Ritalin, Ritalin LA, Ritalin SR, Strattera, Vyvanse, Zenzedi

Doxycycline/Minocycline

Doxycycline products: Adoxa, Alodox, Avidoxy DK, Doryx (and generic equivalents), doxycycline, Monodox, Morgidox Kit, Nicazeldoxy, Nutridox Kit, Ocudox Kit, Oracea, Oraxyl, Vibramycin
Minocycline products: Dynacin, Minocin, Minocin Kit, Solodyn (and generic equivalents)

Erectile Dysfunction (ED)

Caverject, Cialis, Edex, Levitra, Muse, Staxyn, Stendra, Viagra

Fentanyl (Oral/Nasal)

Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys

Narcolepsy

Nuvigil, Provigil
Xyrem is also included in this program. See separate entry in Specialty Prior Authorization section.

Opioid Dependence

Bunavail, Suboxone, Subutex, Zubsolv

Weight Loss

Adipex-P, Belviq, Bontril PDF, Bontril Slow Release, Didrex, Diethylpropion, Phentermine, Qsymia, Regimex, Suprenza, Xenical

Specialty Prior Authorization

Cushing's Disease

Signifor

Enzyme Deficiency

Kuvan

Erythropoiesis Stimulating Agents (ESAs)

Aranesp, Epogen, Procrit

Familial Hypercholesterolemia

Juxtapid, Kynamro

Growth Hormone/Egrifta

Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-tropin, Zorbtive; Egrifta

H.P. Acthar (Pituitary Hormone)

H.P. Acthar Gel

Hepatitis B & C

Incivek, Infergen, Olysio, Pegasys, PegIntron, Sovaldi, Victrelis

Huntington's Chorea

Xenazine

Idiopathic Thrombocytopenic Purpura (ITP)

Nplate, Promacta

Inherited Autoinflammatory Disorders

Arcalyst, Ilaris

Kalydeco (Cystic Fibrosis)

Kalydeco

Multiple Sclerosis

Ampyra

Osteoporosis

Forteo

Pulmonary Arterial Hypertension (PAH)

Adcirca, Letairis, Opsumit, Revatio, Tracleer

Self-Administered Oncology

Afinitor, Afinitor Disperz, Bosulif, Caprelsa, Cometriq, Erivedge, Gilotrif, Gleevec, Hexalen, Hycamtin, Iclusig, Imbruvica, Inlyta, Jakafi, Lysodren, Matulane, Mekinist, Nexavar, Oforta, Pomalyst, Revlimid, Sprycel, Stivarga, Sutent, Sylatron, Tafinlar, Tarceva, Targretin, Tasigna, Temodar, Thalomid, Tretinoin, Tykerb, Votrient, Xalkori, Xeloda, Xtandi, Zelboraf, Zolinza, Zykadia, Zytiga

Short Bowel Syndrome

Gattex

Urea Cycle Disorders

Buphenyl, Ravicti

Xyrem

Xyrem

* Third-party brand names are the property of their respective owners.


More information is available in the prior authorization member flier .


Step Therapy

The step therapy program requires that you have a prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug.


  • A first-line drug is recognized as safe and effective in treating a specific medical condition, as well as being a cost-effective treatment option.
  • A second-line drug is a less-preferred or potentially more costly treatment option.

Step 1: When possible, your doctor should prescribe a first-line medication appropriate for your condition.

Step 2: If your doctor determines that a first-line drug is not appropriate for you or is not effective in treating your condition, your prescription drug benefit will cover a second-line drug when certain criteria are met.

  • Below are drug categories and specific medications for which a step therapy program may be included as part of your prescription drug benefit plan.
  • Step therapy does not apply to the generic equivalents for these medications (if available), so if you and your doctor decide the generic equivalent is best for you, prior authorization is not required.
  • These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.
  • Please note that drug categories may be added and the medications listed are only examples. Call the Pharmacy Program number on the back of your ID card with questions about a specific medication.
  • As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
Drug Category Prescription Drugs within the Category*

Step Therapy

Anticonvulsants

Keppra, Keppra XR, Lamictal, Lamictal ODT, Lamictal XR, Lyrica, Oxtellar XR, Potiga, Qudexy XR, Topamax, Topiramate ER, Trileptal, Trokendi XR, Vimpat

Bisphosphonates (Osteoporosis)

Actonel, Alendronate 40mg tablet and solution, Atelvia, Binosto, Boniva, Fosamax, Fosamax Plus D

Cox-2/NSAID GI Protectant (Pain Management)

Celebrex, Duexis, Vimovo

Depression

Aplenzin, Brintellix, Celexa, Cymbalta, Desvenlafaxine ER tabs, Desvenlafaxine fumarate, Effexor, Effexor XR, Fetzima, fluoxetine 60 mg tabs, Forfivo XL, Lexapro, Luvox CR, maprotiline, Oleptro, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Prozac Weekly, Remeron, Remeron SolTab, venlafaxine ER tabs, Viibryd, Viibryd Starter Kit, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zoloft

Diabetes (GLP-1 Receptor Agonists)

Bydureon, Byetta, Tanzeum, Victoza

Glucose Test Strips

All non-formulary brand test strips and disks (Standard Formulary brands are Bayer and Roche; Generics Plus Formulary brand is Bayer)

Hypertension (High Blood Pressure)

Amturnide, Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Exforge, Exforge HCT, Hyzaar, Micardis, Micardis HCT, Tekamlo, Tekturna, Tekturna HCT, Teveten, Teveten HCT, Tribenzor, Twynsta, Valturna

Insomnia

Ambien, Ambien CR, Edluar, Intermezzo, Lunesta, Rozerem, Silenor, Sonata, Zolpimist

Lipid Management (Cholesterol)

Advicor, Altoprev, Lescol, Lescol XL, Lipitor, Liptruzet, Livalo, Mevacor, Pravachol, Simcor, Vytorin, Zocor

Non-sedating Antihistamines

Clarinex, Clarinex-D 12 Hour, Clarinex-D 24 Hour, Semprex-D, Xyzal

Proton Pump Inhibitors – PPIs (Gastroesophageal Reflux Disease)

Aciphex, Dexilant, Esomeprazole Strontium, First lansoprazole suspension kit, First omeprazole suspension kit, Nexium, omeprazole/sodium bicarbonate, Prevacid, Prilosec, Protonix, rabeprazole, Zegerid

Triptans (Migraine)

Alsuma, Amerge, Axert, Frova, Imitrex, Maxalt, Maxalt-MLT, Relpax, Sumavel DosePro, Treximet, Zecuity, Zomig, Zomig-ZMT

Specialty Step Therapy

Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis)

Actemra subcutaneous, Cimzia, Enbrel, Entyvio, Humira, Kineret, Orencia subcutaneous, Otezla, Simponi, Stelara, Xeljanz

Infertility

Gonal F, Gonal F RFF

Iron Chelator

Ferriprox

Multiple Sclerosis

Aubagio, Avonex, Extavia, Gilenya

* Third-party brand names are the property of their respective owners.


More information is available in the step therapy member flier .

If you have questions about the prior authorization/step therapy program, call the Pharmacy Program number on the back of your BCBSIL ID card.

Generic Drug Information

Prescription drugs can be a costly medical expense. But you can help control your out-of-pocket costs. One way is by choosing generic drugs.

Only your doctor can decide which medication is right for you. But here are answers to some questions you might have about generic drugs.

What are generic drugs?

A generic drug is a version of a brand drug. There are two types of generics:

  • A generic equivalent is made with the same active ingredients at the same dosage as the brand drug. The active ingredients treat your condition or relieve your symptoms. According to the U.S. Food and Drug Administration (FDA), compared to the brand drug, a generic equivalent works the same in the body, meets the same standards set by the FDA and is just as safe and effective. You can expect the same results as with the brand counterpart.
  • A generic alternative is often used to treat the same condition as a brand drug, but contains different active ingredients.

Your pharmacist can often substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. But only your doctor can decide whether a generic alternative is right for you and must prescribe the medication.

Why do generics usually cost less than brand medications?

When a brand drug first becomes available, the manufacturer usually receives a patent. This patent protects their investment in the new drug by keeping other companies from copying and producing it for several years.

When a patent expires, other manufacturers can produce a generic version of the drug. Generic drug manufacturers do not have to make the costly investment in research and development that the brand drug manufacturer did. So, the cost is lower.

Do generic drugs look the same as brand drugs?

A generic may be a different size, shape and/or color than the brand drug.

The active ingredients in a generic equivalent are always the same as the brand counterpart. However, the generic may have different inactive ingredients, such as coating or flavoring. Since more than one manufacturer may produce a generic equivalent of a brand drug, generics also can vary based on the supplier your pharmacy gets the medication from.

Is there a generic equivalent available for the brand drug I'm taking?

Ask your doctor or pharmacist if there is a generic version of the medication you take. Not all prescription medications have a generic equivalent. But there are generic alternatives for many drugs.

How can I learn more about generic drugs?

In addition to talking with your doctor or pharmacist, you can review the generic drugs flier . Talk to your doctor to find out if a generic drug might be an option for you. If you have questions about your prescription drug benefit, call the Pharmacy Program number on the back of your member ID card.

Common Questions

Glucose Meter Offer

Blue Cross and Blue Shield of Illinois offers glucose meters to members with diabetes at no additional charge to help you manage your condition. This offer is available through December 31, 2014. See the glucose meter flier PDF for more information about this offer and monitoring your blood glucose level.

Test strips for the meters offered are on the formulary. If your pharmacy benefit is based on the Generics Plus Formulary, please note that of the meters shown on the flier only test strips for the Bayer meters are included on the formulary.

Vaccine Program

If you have coverage through Blue Cross and Blue Shield of Illinois, vaccinations may be covered under the medical benefit or prescription drug benefit, based on your plan. Select vaccines can be conveniently administered at a pharmacy near you. These vaccines can help protect you and your covered family members from illnesses such as the flu, pneumonia, shingles, rabies, hepatitis B, tetanus, diphtheria and pertussis.

To see which vaccines are covered under your plan, check your benefit materials for details and any necessary copays. Or, you can call the Pharmacy Program number on the back of your ID card.

  • The select vaccines covered under the prescription drug benefit are conveniently administered at a participating vaccine network pharmacy. Just hand your ID card to the pharmacist.
  • To see a complete list of all participating pharmacies, log in to Blue Access for Members and select Prescription Drugs from the Quick Links section on the right-hand side. Or, you can call the number on the back of your ID card.
  • Before you go, be sure to confirm the location's participation and hours, vaccine availability and ask about any other age limits, restrictions or requirements that may apply.

More information is available in the pharmacy vaccine program member flier PDF.