Specialty Pharmacy Benefit Preauthorization Requirement Changes for Some Commercial Members, Effective Jan. 1, 2020
Posted October 1, 2019
We are continuing to make improvements to product offerings and utilization management programs to better serve our customers. This means there will be changes to the preauthorization requirements for some of your Blue Cross and Blue Shield of Illinois (BCBSIL) patients. Specifically, this notice applies to some of our members with Blue Choice Preferred PPOSM and Blue OptionsSM/Blue Choice OptionsSM benefit plans.
For some of these members, beginning Jan. 1, 2020, some new benefit preauthorization requirements will be added, and some existing requirements will be expanded for select outpatient provider-administered drug therapies, such as:
- Cellular immunotherapy,
- Gene therapy; and
- Other medical benefit drug therapies.
An updated Specialty Pharmacy Select Infusion Drug List (Commercial) will be posted on our Provider website as of the implementation date.
As always, it is critical to check eligibility and benefits first, prior to rendering care and services, to confirm coverage, network status and other important details. Benefit preauthorization requirements are specific to the patient’s policy type and procedure(s) being rendered. When you check eligibility and benefits online by submitting an electronic 270 transaction through the Availity® Provider Portal or your preferred web vendor portal, you may determine if benefit preauthorization/pre-notification may be required.
For services requiring prior authorization through BCBSIL:
- At this time, you may continue to submit benefit preauthorization requests via iExchange®, our web-based automated tool.
- If you do not have online access, benefit preauthorization through BCBSIL may be requested by calling the phone number on the member’s ID card.
Payment may be denied if you perform procedures without benefit preauthorization when benefit preauthorization is required. If this happens, you may not bill our members. For more information, refer to
the Eligibility and Benefits and Prior Authorization pages of our Provider website. Also watch the News and Updates and upcoming issues of the Blue Review for announcements, updates and related resources.
This information does not apply to HMO members.
Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized/pre-notified for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. The vendors are solely responsible for the products or services they provide. If you have any questions regarding any of the products or services they provide, you should contact the vendor(s) directly.