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 Blue Cross Medicare Advantage Dual Care (HMO SNP)SM drug list.

Prior Authorization

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

Step therapy requires the use of one or more specific drug(s) prior to the use of a more potent dosage or higher quantities of a drug.
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Medication Therapy Management Programs

Blue Cross Medicare Advantage offers medication management programs for members who have multiple chronic conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for Blue Cross Medicare Advantage by a team of pharmacists and doctors.

We use these medication management programs to help us provide better care for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify medication problems. Please note that these programs may have limited eligibility criteria and are not considered a benefit under Blue Cross Medicare Advantage .

To learn more about our medication management programs, or to join a program, contact a Product Specialist.

Drug Utilization Review

Blue Cross Medicare Advantage 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.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. This plan is available to anyone who has both Medical Assistance from the State and Medicare.

*Some network pharmacies are not preferred and therefore do not offer lower copays for a 90-day supply.