Part D Quality Assurance & Utilization Management

Utilization Management

Certain covered drugs may have requirements or limits on coverage. Our staff works with a team of outside healthcare providers to help determine these requirements. They are designed to ensure that prescription drugs are used in a safe and effective way while helping to control drug plan costs. You can find out if your drug has any of these requirements or limits on coverage by looking in the formulary. These requirements or limits may include:

  • Prior Authorization: We require prior authorization for certain drugs. This means that your doctor will need to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug. Learn more about Prior Authorization Criteria.
  • Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Learn more about Step Therapy Criteria.
  • Quantity Limits: For certain drugs, Blue Advantage limits the amount of the drug that the plan will cover per prescription or for a defined period of time. For example, Blue Advantage provides 18 tablets per 28 day prescription for sumatriptan.
  • Generic Substitution: In most cases, when there is a generic version of a brand-name drug available, our network pharmacies will give you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)

If your drug is subject to one of these additional restrictions or limits, and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

Drug Utilization Review

We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe 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, we look 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 not safe or appropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking at the same time
  • Drug allergies
  • Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Safe Use of Pain Medicines

We are committed to improving the health and lives of our members. Learn more about how to safely use opioid pain medications and what features we use to protect you when filling your prescriptions.

Y0132_19-529_ITLU - Last updated 01/30/2020