Our plan has programs in place to ensure you receive safe and appropriate care. Our programs include current and historic review of claims. These reviews are in place to reduce drug errors that cause adverse drug interactions. Our reviews are important if you use more than one drug, have more than one pharmacy, or have more than one doctor who is prescribing drugs.
Drug and Utilization Review Programs
When a pharmacy sends a prescription claim, we look at the claim for:
- Age related problems.
- Overuse and underuse.
- Issues with other drugs you take.
- Issues with a disease you have.
- Wrong drug dosage.
- Wrong length of therapy.
- Drug/allergy issues.
- Abuse or misuse.
For questions about our quality programs contact Member Services.
Drug Management Program
Our Drug Management Program monitors our members’ safe and effective use of opioid prescription drugs like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine.
Taking opioid drugs can help with certain types of pain after an injury or surgery. Taking them also comes with serious risks like addiction, overdose and death. These risks can increase if you take high doses, or take opioids with certain other drugs like benzodiazepines (Xanax®, Valium®, Klonopin®) for anxiety and sleep.
The program’s goal is to help you, your doctor and your pharmacy ensure that you are prescribed the correct drugs for pain and you take them safely.
When you fill a prescription, your pharmacist will review all the drugs that you take to check for:
- Potentially unsafe amounts
- Interactions with other drugs like benzodiazepines
A new prescription may be limited to a seven-day supply or less. This limit does not apply if you have been taking an opioid.
If your prescription can’t be filled, your pharmacy will give you a notice explaining how to ask us for a coverage decision. If your health requires it, you can ask us for a fast coverage decision. You also can ask us for an exception to our rules before you go to the pharmacy so you’ll know if we will cover your drug.
How our Program Works
If you get an opioid drug from more than one doctor, we may talk with your doctors to make sure you need the drug and that you’re using it safely. If we decide your use of the drug isn’t safe, we may limit your coverage. For example, to better coordinate your care, we may require you to get the drug only from certain doctors or fill them at certain pharmacies.
Before we place you in our program, we will send you a letter to explain our review of your drug history. You then can tell us which doctors or pharmacies you prefer to use to get your drugs. If we limit your coverage, we will send you another letter to explain what you and your doctor can do to appeal our decision.
Our program does not apply to you if you have cancer, or if you receive hospice, palliative or end-of-life care, or if you live in a long-term care facility.
Your Provider Can Help
Talk with your doctor about all of your pain treatment options. Then decide what is right for you. You could take other drugs or do other things to manage your pain with less risk.
Contact Member Services if you have questions about our Drug Management Program.
For more information on safe and effective pain management visit:
- The Centers for Disease Control and Prevention (CDC) website at: https://www.cdc.gov/drugoverdose/patients/ or https://www.cdc.gov/drugoverdose/epidemic/index.html
- The U.S. Department of Health and Human Services website at https://www.hhs.gov/opioids/
- The Medicare.gov website, https://www.medicare.gov/ or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Get information 24 hours a day, 7 days a week.
See 2020 information for more details.