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:
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:
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.