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Utilization management tools, such as prior authorization, quantity limits and step therapy, apply to select drugs on the plan's drug list to ensure safe and cost-effective use.
Prior authorization is required on some medications. This means that specific criteria must be met before a drug is covered.
Prior Authorization Criteria and Form
Quantity limits are applied to certain drugs based on the approved dosing limits established during the Food and Drug Administration (FDA) approval process and are utilized to ensure safe drug use. Quantity limits are applied to the number of units dispensed for each prescription.
Quantity Limits Exception Form
Step therapy requires that you first try certain commonly used formulary drugs to treat your medical condition before we will cover another drug for that condition.
Step Therapy Criteria and Form
Blue Cross Medicare AdvantageSM conducts drug utilization reviews for all of our members to ensure they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor prescribing their medications.
We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, Blue Cross Medicare Advantage looks for medication problems such as:
If Blue Cross Medicare Advantage identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem.