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Some drugs have additional rules and restrictions around when and how often they can be used. These rules are generally called utilization management.
The following are examples of utilization management tools:
Some drugs have specific rules that must be met before they can be prescribed. This is called prior authorization.
Your doctor must complete a prior authorization form and fax it to Medi-CareFirst for approval before the prescription can be filled. The formulary shows whether a drug requires prior authorization and provides a link to the Prior Authorization Form for that drug. Click here to access the list of drugs requiring prior authorization.
If you do not get prior authorization, Medi-CareFirst may not cover your drug. In some cases, you may be required to try a specific drug to treat your condition before Medi-CareFirst will approve a different drug.
Some drugs have limits on the amount of the drug you can get during a specific time period. These are called quantity limits.
Information on quantity limits and Quantity Limit Exception Request Forms can be found in the formulary. Click here to access the list of drugs with quantity limits.