Information about Blue Cross and Blue Shield of Minnesota pharmacy utilization management programs
Below is a list of Blue Cross and Blue Shield of Minnesota and Blue Plus pharmacy benefit drug utilization management (UM) program summaries. The summary policies outline which drugs may require prior authorization, step therapy and/or quantity limits.
Search tip:
Search by drug name, drug class or condition. While some pharmacy UM program criteria titles may include specific drug names, some titles may be for a group (or class) of drugs.
More information:
- Upcoming pharmacy policy notifications
- Electronic prior authorization of prescription drugs
- Policies for drugs covered under the medical benefit
- Prior authorization formulary exception form
- FEP pharmacy (CVS Caremark) prior authorization information
- Prescription drug programs
- Provider feedback for pharmacy UM criteria:
- Complete the provider feedback form for clinical policies/guidelines/criteria
- Email the form to: policy.provider.feedback@bluecrossmn.com
Note: Not all employer groups retain Prime Therapeutics as their pharmacy benefits manager (PBM). The pharmacy policies content only applies to those employer groups who retain Prime Therapeutics. Member ID cards with RxBIN 610455 and RxPCN PGIGN or HMHS on the front indicate that a member has Prime Therapeutics as their PBM and these pharmacy policies apply.
| Pharmacy UM Program Criteria Sort descending | Program Type | Program Effective Date | Status |
|---|---|---|---|
| Dojolvi® (triheptanoin) - Medicaid | Prior Authorization | Active | |
| DPP-4 (dipeptidyl peptidase-4) Inhibitors and Combinations - Commercial | Step Therapy, Quantity Limit | Active | |
| DPP-4 (dipeptidyl peptidase-4) Inhibitors and Combinations - Medicaid | Step Therapy, Quantity Limit | Active | |
| Droxia®, Siklos® (hydroxyurea) - Medicaid | Prior Authorization | Active | |
| Egrifta® (tesamorelin) - Commercial | Prior Authorization, Quantity Limit | Active | |
| Egrifta® (tesamorelin) - Medicaid | Prior Authorization, Quantity Limit | Active | |
| Elagolix/Relugolix - Commercial | Prior Authorization, Quantity Limit | Active | |
| Elagolix/Relugolix - Medicaid | Prior Authorization, Quantity Limit | Active | |
| Elmiron® (pentosan polysulfate sodium) - Commercial | Prior Authorization | Active | |
| Elmiron® (pentosan polysulfate sodium) - Medicaid | Prior Authorization | Active |