Utilization Management

This program incorporates utilization management tools and policies to encourage an appropriate and cost-effective use of Part D medications. A team of doctors and pharmacists developed these policies, requirements, and limits to help us provide quality coverage to our members. These tools include‚ but are not limited to: prior authorization‚ clinical edits‚ quantity limits, and step therapy.

Age limits

Some drugs may require a prior authorization if your age does not meet the manufacturer, Food and Drug Administration (FDA), or clinical recommendations.

Quantity limits

For certain drugs, we limit the amount of the drug we will cover per prescription or for a defined period of time.

Prior authorization

We require you to get prior authorization for certain drugs. This means you will need to get approval from us before you fill your prescriptions. You, your doctor, other prescriber or appointed representative will need to contact Blue Shield of California Promise Health Plan to provide clinical information. If you don’t get approval, Blue Shield of California Promise Health Plan may not cover the drug.

Learn more about the drug coverage decision process.

Step therapy

In some cases, we require that you 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.

Review the list of drugs requiring step therapy.

Generic substitution

When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher copay and/or the difference in cost between the brand and generic medications.

You can find out if your drug is subject to any one of these policies by looking in the Blue Shield Promise Medicare Plan Formulary.

Quality assurance policies

Blue Shield of California Promise Health Plan has established measures and systems to conduct drug utilization reviews for all of our members to make sure they are getting safe and appropriate care.

The programs include real-time and historic review of prescriptions claims to reduce medications errors and adverse drug interactions. These reviews are especially important for members who have more than one doctor prescribing their medications, use more than one drug, or have more than one pharmacy.

Blue Shield of California Promise Health Plan conducts drug utilization reviews when your pharmacy fills your prescription at the point-of-sale. The claim may be electronically reviewed for the following:

  • Duplicate drugs, multiple prescriptions that are not all necessary because they treat the same medical condition
  • Age-related contraindications
  • Gender-related contraindications
  • Drug interactions
  • Incorrect drug dosage
  • Incorrect duration of therapy
  • Clinical abuse or misuse

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.