Utilization Management
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:
Prior Authorization
Some drugs have specific rules that must be met before they can be dispensed by your pharmacist. This is called prior authorization. Covered drugs that need prior authorization are marked in the formulary.
You or your doctor may complete the Coverage Determination form. To speed up the prior authorization request, we suggest that your doctor complete the prior authorization form for the specific drug you need and fax the completed form, along with any supporting documentation, to the number on the form. You can access the list of drugs that require Prior Authorization on our formulary page by clicking on the "Drugs that Require Prior Authorization" link.
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.
Quantity Limits
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. You can access the list of drugs with quantity limits on our formulary page by clicking on the "Drugs with Quantity Limits" link, as well.