For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:
Prior Authorization: We require you to get prior authorization for certain drugs. This means that your physician will need to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug.
Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 30 tables per prescription for LIPITOR.
Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.
You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules.
Drug utilization review
We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:
Possible medication errors.
Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
Drugs that are inappropriate because of your age or gender.
Possible harmful interactions between drugs you are taking.
Drug dosage errors.
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
Medication therapy management programs (MTMP)
We offer medication therapy management programs at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.
We offer a medication therapy management program(s) for members that meet specific criteria. We may contact members who qualify for these programs. If you are selected to join our medication therapy management program we will send you information about the specific program by letter. If we contact you, we hope you will join so we can help you manage your medications. Remember, you do not need to pay anything extra to participate.
If selected, you will be offered a Comprehensive Medication Review (CMR), an interactive consultation, on an annual basis. This CMR offer letter will be sent out to you no later than 60 days after being enrolled in the MTM program. The results of the CMR consultation will be summarized in an individualized, written summary. Also, if any clinical interventions are identified, they will be provided as a targeted medication review and mailed to you on a quarterly basis.
The medication therapy management programs we offer are not considered a benefit. For more information, please contact customer service at 1-866-314-2427, TTY/TDD 1-888-205-7671, from 8:00 AM to 8:00 PM, 7 days a week (PT). Medicare also provides program forms, documents, and additional information on their website: http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html
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