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Quality Assurance Policy and Procedures

What is 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 help us control drug plan costs so we can pass on savings to members. A team of doctors and pharmacists developed these requirements and limits to help us to provide quality care 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 you will need to get approval from us before you fill your prescription. If you don’t get approval, we may not provide coverage for 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 tablets per prescription for HYSINGLA ER per 30 days.
  • Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will provide coverage for another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, we will then provide coverage for 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 our formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. See the section, “How do I request an exception to the formulary?” for more information.

Drug Utilization Review and Quality Assurance

We conduct drug utilization reviews for all of our members to make sure that you 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 inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • 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.

Medication Therapy Management (MTM)

Find out more information about the CareFirst Medicare Advantage Medication Therapy Management program.