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Utilization Management

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A utilization management tool applies to select drugs to ensure safe and cost-effective use of drugs on the Blue Medicare Advantage formulary.

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 you to first try a less costly but just as effective drug to treat your medical condition before we will cover the more costly drug your physician initially prescribed.
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Medication Therapy Management Programs

Blue Medicare Advantage^SM 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 Medicare Advantage by a team of pharmacists and doctors.

We use these medication management programs to help us provide better care for our members. 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 Medicare Advantage.

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

Drug Utilization Review

Blue 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 Medicare Advantage looks for medication problems such as:

• Possible medication over or under use
• 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 Medicare Advantage identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

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 Medicare Advantage.