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Drug Management Programs*

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Utilization management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult your copy of our formulary or the formulary on our Web site for more information about these requirements and limits. The requirements for coverage or limits on certain drugs are listed as follows:
 

Prior Authorization: We require you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don't get the necessary information to satisfy the prior authorization, we may not cover the drug.
 

• Medicare Plus Blue PPO^SM Prior Authorization/Step Therapy Criteria (PDF 137K)
• Medicare Plus Blue PFFS^SM and Prescription Blue PDP^SM Prior Authorization/Step Therapy Criteria (PDF 139K)

 

Step Therapy: In some cases, we require you to first try one drug 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 require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
 

• Medicare Plus Blue PPO^SM Prior Authorization/Step Therapy Criteria (PDF 137K)
• Medicare Plus Blue PFFS^SM and Prescription Blue PDP^SM Prior Authorization/Step Therapy Criteria (PDF 139K)

 

Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 31 tablets per 31-day supply for a formulary drug.
 

• Medicare Plus Blue PPO^SM Quantity Limit Restrictions (PDF 60K)
• Medicare Plus Blue PFFS^SM and Prescription Blue PDP^SM Quantity Limit Restrictions (PDF 60K)

 

Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies may recommend and/or provide you the generic version, unless your doctor has told us that you must take the brand-name drug and we have approved this request.
 

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary or on our Web site, or by calling Customer Service. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren't able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination). See your Evidence of Coverage for more information about how to request an exception.
 

Drug utilization review*

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes 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 inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• 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.
 

Medication therapy management programs*

We offer medication therapy management programs at no additional cost to members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage 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 possible medication errors.
 

We may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you don't need to pay anything extra to participate.
 

If you are selected to join a medication therapy management program we will send you information about the specific program, including information about how to access the program.
 

If you have questions regarding these programs, please contact us.
 

* These programs have limited eligibility criteria and are not considered a benefit.