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Utilization Management

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 plan's drug list.

Your doctor can submit the forms listed below using MyPrime1 or CoverMyMeds®.

Types of Utilization Management

Prior Authorization

Some drugs need to be approved by the plan before they are covered. This is so the plan can best guide the correct use of these drugs. Your doctor can help you get approval.

Prior Authorization Criteria and Form

Quantity Limits

There can be limits on how much of a drug you’re allowed. The limit could be for how many pills you get with each prescription. These limits are based on safety guidelines.

Quantity Limits Exception Form

Step Therapy

The plan can ask you to start treatment with a drug that costs less but works just as well (for example, a generic name drug) instead of starting with a drug that costs more. If the first drug doesn’t work for you, then the plan will cover the higher-priced drug.

Step Therapy Criteria and Form
 

Drug Utilization Review

Drug utilization reviews help make sure you’re getting safe and proper care. They are very important if you have more than one doctor prescribing your medications. The review is done each time you fill a prescription, as well as on a regular basis. We look for issues such as:

  • Medication errors
  • A drug that may not be needed because you are taking another drug to treat the same medical condition
  • Drugs that are not right for you because of your age or sex
  • Possible harmful interactions between drugs you are taking
  • Drug allergies
  • Dosage errors

If we find a problem during the review, we’ll work with your doctor to fix it.

1MyPrime.com is a pharmacy benefit website owned and operated by Prime Therapeutics LLC, a separate company providing pharmacy benefit management services for your plan.