Whether you take medication to manage an ongoing health condition or you need a prescription for an illness, you will want to become familiar with your health care plan's drug list. This is a list of covered drugs that are available to BCBSIL members.
Both brand and generic medications are included on the drug list. The drug list has different levels of coverage, which are called "tiers." Generally, if you choose a drug that is a lower tier, your out-of-pocket costs for a prescription drug will be less.
The drug list is not a substitute for the independent medical judgment of your health care provider. The final decision on what prescription drug is appropriate for you is between your health care provider and you.
You can view your drug list here. Be sure to choose the section that describes your plan.
When You Can Request a Coverage Exception
If your medication is not on (or has been removed) from your drug list, you or your prescribing doctor may want to request a coverage exception.
To request this exception, your prescribing doctor will need to send BCBSIL documentation. To begin this process, you or your doctor can call the BCBSIL Customer Service number listed on your member ID card for more information.
You or your doctor can also fill out and submit the Prescription Drug Coverage Exception form. You will need to provide us with your doctor's name and contact information as well as the name and, if known, the strength and quantity of the drug being requested.
BCBSIL will let you or your doctor know of the benefit coverage decision within 72 hours of receiving your request. If the coverage request is denied, BCBSIL will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination (see below for more information).
You or your doctor may be able to ask for an expedited review if:
- You take medication for a health condition and failure to get that medication may either pose a risk to your life or health or could keep you from regaining maximum function
- Your current drug therapy uses a non-covered drug
If your review is expedited, BCBSIL will let you or your doctor know of the coverage decision within 24 hours of receiving your request. If the coverage request is denied, BCBSIL will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination.
How to Appeal a Drug Coverage Exception Determination
If your coverage request is denied, you may request an appeal through BCBSIL verbally by calling the customer service number on your member ID card or by written request to:
Blue Cross and Blue Shield of Illinois
Claim Review Section
PO Box 660603
Dallas, TX 75266-0603
Fax: 1-888-235-2936
If you or your doctor believe that your life or health could be threatened by waiting for a standard Appeal, an expedited Appeal can be requested by calling1-800-458-6024 or by fax at 1-918-551-2011.
If a denial is upheld on an Appeal, your case may qualify for an external review with an Independent Review Organization (IRO). If your case qualifies for external review, an IRO will review your case, at no cost to you, and make a final decision. If your request is Urgent or Expedited, an external review with an Independent Review Organization (IRO) may be requested at the same time as your Appeal, or instead of an Appeal. To ask for an external review, please complete the External Review form that was included with your denial. If your policy follows the State process, you will submit the form to:
Illinois Department of Insurance
Office of Consumer Health Insurance
External Review Unit
320 W Washington Street
Springfield, IL 62767-0001
Contact the Illinois Department of Insurance External Review Request line at1-877-850-4740. You may also email[email protected]or send a fax to1-217-557-8495.
If your policy follows the Federal process, you will submit to:
BCBSIL- External Review Request
PO Box 660603
Dallas, TX 75266-0603
Fax: 1-972-907-1868
If you have any questions about requesting a coverage exception, call the BCBSIL Customer Service number listed on your member ID card.
