Drug Utilization Review and Management

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps drug coverage more affordable.

In general, whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan’s rules are designed to encourage the use of that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

We also have special programs to help members use their drugs safely. We conduct drug utilization reviews for our members to ensure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time a prescription is filled. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

  • Possible medication errors
  • Drugs that may not be necessary because another drug is being taken to treat the same medical condition
  • Drugs that may not be safe or appropriate because of age or gender
  • Certain combinations of drugs that could cause harm
  • Prescriptions written for drugs that have ingredients the member is allergic to
  • Possible errors in the dosage of a drug

If we see a possible problem, we will work with the provider to correct it.

Opioid Safety Alerts and Drug Management Program

The opioid policies for Medicare drug plans include improved opioid safety alerts when opioid prescriptions are dispensed at the pharmacy and drug management programs for members inappropriately using opioids. The below documents, in part, explain these policies.

Medicare Part D Opioid Policies Summary - This brief document summarizes the policies.

Medicare Part D Opioid Policies Guide - This guide provides more information about the policies including myths and facts, the drug management program case management process, coverage limitations, and appeals process.