Part D Quality Assurance & Utilization Management

Utilization Management

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 the following requirements and limits for our plans to help us provide quality coverage to our members:

  • Prior Authorization: We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug.
  • Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
  • 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.
  • 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 the drug you take is subject to these additional requirements or limits by looking in the Drug Formulary. If your drug is subject to one of these additional restrictions or limits, and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

Drug Utilization Review

We conduct drug utilization reviews for all of our members to make sure that 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 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 not safe or appropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking at the same time
  • Drug allergies
  • Drug dosage errors

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

Y0027_18-330 - Last updated 12/20/2018