Utilization Management

Utilization management tools, such as prior authorization, quantity limits and step therapy, apply to select drugs to ensure safe and cost-effective use of drugs on the plan’s drug list.

Prior Authorization

Prior authorization is required on some medications. This means that specific criteria must be met before a drug is covered.

Quantity Limits

Quantity limits are applied to certain drugs based on the approved dosing limits established during the Food and Drug Administration (FDA) approval process. Quantity limits are applied to the number of units dispensed for each prescription.

Step Therapy

Step therapy requires that you first try certain drugs to treat your medical condition before we will cover another drug for that condition.

Drug Utilization Review

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:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug allergies
  • Drug dosage errors

If Blue Cross Medicare Advantage identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem.