Our plan uses different types of utilization management tools to help our members use drugs in the most effective ways.
Prior Authorization: Approval in advance to get certain drugs that may or may not be on our formulary.
For covered drugs requiring “Prior Authorization” your prescribing provider will need to include any clinical information and supporting documentation along with the Request for Medicare Prescription Drug Coverage form.
Step Therapy: A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
Quantity Limits: A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.
Our searchable “online” formulary and downloadable PDF formulary provides a comprehensive listing of all drugs that are covered by CareFirst Medicare Advantage. For each drug listed we let you know if there is any utilization management tool or restriction to the drug.
In addition, our searchable “online” formulary will also provide you with the applicable clinical criteria for each drug that has a utilization management tool/restriction.