Utilization Management


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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.

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 more potent dosage or higher quantities of a drug.
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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.

*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.