Viewing the Formulary & Understanding Utilization Management

Blue Advantage Formulary

The formulary is the list of medications that are covered by your Blue Advantage plan. You can use the formulary to find out if the medications you take are covered and at what cost to you. The formulary can also be helpful when working with your doctor to decide which medications can help treat you while also keeping your costs as low as possible.

Blue Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed.

2024 Formulary Last Updated 07/01/2024
2024 Formulary - DSNP Last Updated 07/01/2024
2023 Formulary Last Updated 12/01/2023

Occasionally, our drug formulary may change during the year. These changes will be updated regularly, and you can find them by clicking the button below.

2024 Formulary Change Notice

Utilization Management

Certain covered drugs may have requirements or limits on coverage. Our staff works with a team of outside health care providers to help determine these requirements. They are designed to ensure that prescription drugs are used in a safe and effective way while helping to control drug plan costs. We've included a few examples below, but you can find out if your drug has any of these requirements or limits on coverage by looking in the formulary above.

Prior Authorization

We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from the plan before you fill your prescription. If they don't get approval, we may not cover the drug. Click on the link below to view the prior authorization criteria used by the plan to determine if the drug is covered.

2024 Prior Authorization Criteria

Step Therapy

We may require that you try one or more alternative drugs for your health condition before we will cover the drug you are requesting. If you have already tried other drugs or your doctor thinks other drugs are not right for your situation, you or your doctor can ask the plan to cover the requested drug. Click on the link below to view the step therapy criteria used by the plan.

2024 Step Therapy Criteria

Quantity Limits

For certain drugs, Blue Advantage limits the amount of the drug that the plan will cover per prescription or for a defined period of time. For example, Blue Advantage provides 18 tablets per 28-day prescription for sumatriptan. If there are quantity limits on a specific drug, you can find that by looking in the formulary.

Generic Substitution

In most cases, when there is a generic version of a brand-name drug available, our network pharmacies will give you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)

Did You Know?

Blue Advantage conducts drug utilization reviews for all members to ensure they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct reviews each time you fill a prescription and on a regular basis by reviewing our records. We look for medication problems such as:

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Now that you understand more about your pharmacy benefits, you're on the right path to maintaining and improving your health. Become a pro by learning how to easily get your needed prescriptions and about the prescription support programs offered by Blue Advantage!

Getting Your Prescription Drugs

As a Blue Advantage member, you can use these money and time-saving tools - like a three-month supply - to make getting your prescriptions even easier!

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Prescription Support Programs

We know that taking your drugs as your doctor orders can mean better health outcomes for you. That's why we offer you support to help you stay on track.

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We're always happy to help!

Just a Phone Call Away

Reach out to us for help or any questions you may have about your health care coverage and plan benefits.

Call us at: 1-866-508-7145 (TTY 711). Our phone lines are open 8 a.m. to 8 p.m., 7 days a week from October - March and 8 a.m. to 8 p.m., Monday - Friday from April - September

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