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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 SM drug list.
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.
Blue Cross Medicare AdvantageSM 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 potential 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.
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:
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.
*Some network pharmacies are not preferred and therefore do not offer lower copays for a 90-day supply.
PrimeMail is offered by Prime Therapeutics. Prime Therapeutics is a separate company from Blue Cross and Blue Shield of Illinois and provides pharmacy benefit management services for Blue Cross Medicare Advantage.