Prior Authorization Support Materials (Government Programs)

The resources on this page are intended to help you navigate prior authorization requirements for Blue Cross and Blue Shield of Illinois (BCBSIL) government programs members enrolled in any of the following plans:

• Blue Cross Medicare Advantage (PPO)^SM (MA PPO)
• Blue Cross Medicare Advantage HMO Non-Delegated Model^SM (MA HMO Non-Delegated)
• Blue Cross Community Health Plans^SM (BCCHP^SM)
• Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM

Always check eligibility and benefits first through Availity^® or your preferred web vendor portal to confirm coverage and other important details, including prior authorization requirements and vendors, if applicable. For some services/members, prior authorization may be required through BCBSIL. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore)  for utilization management and related services.

Government Programs Prior Authorization Summary and Code Lists
Refer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. Procedure code lists are provided for reference purposes.

MA PPO/HMO Non-Delegated

• 2022 MA PPO and MA HMO Non-Delegated Prior Authorization Requirements Summary  
• 2022 MA PPO and MA HMO Non-Delegated Prior Authorization Code List  

Medicaid

• 2022 Medicaid Prior Authorization Requirements Summary  
• 2022 Medicaid Prior Authorization Code List  

Summary/Code List Archive

Pharmacy Benefit Prior Authorization Requirements – Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of prior authorization requests from physicians for BCBSIL members with prescription drug coverage. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list  and MMAI drug list. 

Clinical Review Criteria
Utilization management reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan. Use the links below to view BCBSIL and vendor guidelines that may apply.

• BCBSIL Medical Policies
• eviCore healthcare (eviCore) 
• American Society of Addiction Medicine (ASAM)* 
• Davis Vision 
• DentaQuest 
• Illinois Department of Human Services/Division of Mental Health  – Medical Necessity Criteria and Guidance Manual
• Illinois Department of Health and Family Services Medicaid Provider Handbooks 
• MCG^TM Care Guidelines (Accessible to providers through the BCBSIL-branded Payer Spaces section in Availity  under the Resources tab – use CTRL+F to locate specific criteria within the MCG Care Guidelines. BCBSIL members can view guidelines through Blue Access for Members^SM.)
• Medicare Coverage Database (MCD)   – National and Local Coverage Determination (NCD)/(LCD)
• Prime Therapeutics 

*Licensee's use and interpretation of the American Society of Addiction Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.

Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider. 

The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information.  

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. eviCore healthcare (eviCore) is an independent company that has contracted with BCBSIL to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.  

The ASAM Criteria^®, ©2021 American Society of Addiction Medicine. All rights reserved.

Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL.

DentaQuest is an independent company that provides dental benefits for BCBSIL’s Medicaid plans.

MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the conditions of the patient in determining the appropriate course of treatment. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.