Pharmacy Program Updates: Prior Authorization Changes Effective Sept. 15, 2026

By September 1, 2026: Billing and prior authorization teams must: (1) Review the complete PA criteria updates for all 24 affected drug classes on the Prior Authorization and Step Therapy Programs page at bcbsil.com; (2) Update billing system PA rules and workflows to reflect new criteria for Bempedoic Acid, Hetlioz, Leucovorin, VMAT2 Inhibitors, and Vowst (effective 9/15/2026), then subsequent drugs with later effective dates through January 1, 2027; (3) Communicate updated PA requirements to all prescribing providers via email and staff meetings, emphasizing staggered implementation dates; (4) For patients on affected medications (especially opioids, biologics, PCSK9 inhibitors, and weight management drugs), verify eligibility and current plan PA requirements before each prescription fill. By October 1, 2026: Prior auth staff must be prepared to process updated criteria for eight additional drug classes. Update internal PA decision trees and training materials. Note: The policy specifically mentions Prime Therapeutics administers these benefits—verify member ID card to confirm coverage before applying these criteria. Failure to apply correct PA criteria may result in claim denials or appeals.