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November 2015

Medical Drug Utilization Management Program to include limits on some medical drugs

Blue Cross Blue Shield of Michigan is expanding its utilization management program to include some limits on medical drugs administered under the professional medical benefit. This effort will begin in January and continue through the first two quarters of 2016.

One or more of the following drug limits will be enforced on some medical drugs:

  • Maximum dose per day
  • Interval time periods (how often a drug can be administered)
  • Lifetime maximums (number of doses per lifetime)
  • Number of doses per time period

Note: Not all medical drugs will have a quantity limit.

These limitations are based on U.S. Food and Drug Administration and manufacturer labeling, as well as Blue Cross medical and drug policies.

You can find the specific quantity limitations on web-DENIS:

  • Click on BCBSM Provider Publications and Resources.
  • Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
  • Click on Physician administered medications (on the right side under Frequently Used Forms).
No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.