Prescription Drugs Questions and Answers

Are utilization management requirements placed only on preferred drugs?

Quantity limits and step therapy programs may be on preferred and non-preferred drugs. Refer to the quantity limit drug list and step therapy drug list available on our website.

Why would a utilization management requirement be applied to a drug?

Certain drugs have quantity limits to encourage appropriate drug use, enhance drug therapy and reduce costs.

How do I request a utilization management authorization?

Refer to the Quantity Limit or Step Therapy information available on our website.

How long will the utilization management review take?

It will take approximately five to ten business days to complete the evaluation process.

What happens if the utilization management request is approved?

An electronic override is established in the claims system allowing coverage at your next visit to the pharmacy.

What if my utilization management request is not approved?

You may purchase the drug at your own expense.

What happens if I pay full price for the drug upfront and I am then notified my request has been approved? Will I be reimbursed?

You will be reimbursed minus your applicable copay. Please contact Customer Service at the number provided on your BlueLink TPA member identification card for instructions on how to submit this claim for reimbursement.

If the quantity limit override is approved, will I be allowed to receive the balance of my original prescription?

You will not be able to obtain the balance of your original prescription. Regulations prohibit a pharmacist from resubmitting a prescription for a narcotic to allow the fill of the original amount. Therefore, once a quantity limit override is approved, you will have to get a new prescription written by your physician and bring it to the pharmacy to be filled.

The drug I take required a prior authorization (PA) and now the drug is subject to a step therapy program. Does my doctor need to submit a new prior authorization request form and a step therapy request form for this current drug I am taking?

As long as your PA has not expired, a new PA request form is not needed. If your doctor feels your current drug is the most appropriate for you then a Step Therapy Authorization form must be submitted and approved by BlueLink TPA.