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Quality Assurance

We have developed a system of checks and balances to help you get the right medications, in the right amounts, at the right times. Our goal is to avoid potential health risks to you, to keep the plan affordable, and to help those who need it the most to manage their medications.

Medication Therapy Management Programs

Helping Those with Chronic or Serious Conditions

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. If you fit these criteria, you may be invited into the program.

Medication Therapy Management Programs are available for the following conditions and situations:

  • At least two of the following disease states: Hepatitis C, anemia, rheumatoid arthritis, metabolic syndrome, chronic pain, asthma, COPD
  • At least two medications used to treat the above conditions
  • Likely to incur $4,000 in drug costs per year

Drug Utilization Review

Avoiding Problems with Your Prescribed Medicines

We conduct Drug Utilization Reviews (DUR) for our members. These reviews are especially important for members with more than one doctor prescribing their medications.

Each time you fill a prescription, we check:

  • Possible medication or dosage errors
  • Possible harmful interactions
  • Drug allergies
  • Duplication of drugs
  • Drugs that are inappropriate because of your age or gender.
How the DUR system works

Your pharmacist enters your prescription online, where it is reviewed against all your previous prescriptions from the various pharmacies that are in the system. If we identify a potential medication problem, we will discuss it with your pharmacist and/or doctor to correct the problem. Your pharmacist or doctor may also call you.

The following checks are completed online, in real time, as a prescription is being dispensed:

  • Duplicate drug therapy
  • Too-early refill
  • Low-dose/high-dose alert
  • Incorrect daily dosage
  • Excessive or questionable days’ supply
  • Drug-to-drug interaction
  • Drug age/gender interaction
  • Drug-pregnancy interaction
Helping your doctor(s) manage your medicine

We may notify physicians about potential problems with certain drugs. A targeted drug utilization review helps identify members who may be:

  • Receiving improper medicines or high doses
  • Getting the wrong combinations of products
  • Abusing narcotics

Utilization Management

Addressing the Increasing Cost of Drugs

A team of doctors and pharmacists developed requirements and limits on certain drugs to help the plan manage drug usage. The idea of utilization management is to keep plan costs down as prescription costs go up.

How utilization management may affect you:

  • Prior Authorization. This means that physicians will need to get approval from us before you fill your prescription for certain drugs. 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.
  • Generic Substitution. When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version.

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 requirements or limits, you can ask us to make an exception to our coverage rules. See Exceptions and Appeals for more information.

For more information, contact Customer Service.

If you are a member and have questions, contact Customer Service via email or call the number listed on the back of your ID card, 8 a.m. to 8 p.m., seven days a week.