Utilization and Medical Management
What is Utilization Management?
For certain prescription drugs, the plan has additional requirements for coverage or coverage limits. These requirements and limits ensure plan members use these drugs in the most effective way and help the plan control costs and can pass on savings to members. A team of doctors and pharmacists developed these requirements and limits to help the plan provide quality care to its members. Examples of utilization management are described below:
Prior Authorization: The plan requires you to get prior authorization for certain drugs. This means you will need to get approval from the plan before you fill your prescription. If you don’t get approval, the plan may not provide coverage for the drug.
Quantity Limit (QL): For certain drugs, the plan limits the amount of the drug it will cover per prescription or for a defined period of time.
Step Therapy (ST): In some cases, the plan requires you to first try one drug to treat your medical condition before it will provide coverage for another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the plan may require your doctor to prescribe Drug A first. If Drug A does not work for you, the plan will then provide coverage for Drug B.
Generic Substitution: When there is a generic version of a brand name drug available, the plan’s network pharmacies will automatically give you the generic version; unless your doctor has told the plan you must take the brand name drug.
You can find out if your drug is subject to these additional requirements or limits by looking at the plan's formulary. If your drug does have these additional restrictions or limits, you can ask the plan to make an exception to its coverage rules. You can request an exception to the formulary by using the form at the bottom of this web page.
Drug utilization review:
Simply Healthcare has system edits in place that apply to claims at the pharmacy to make sure you are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications or receives medications from more than one pharmacy. These edits look for medication problems such as:
- Duplicate medications
- Drugs inappropriate for your age or gender
- Drug dosage errors
- Drug interactions
- “Refills too soon” – to make sure you are taking the medications as directed by your doctor
Simply Healthcare or their designated provider will also review claims to determine the drug utilization patterns of members (i.e. over and under utilization) and physician’s prescription patterns. Simply Healthcare may contact physicians or members to discuss these utilization and prescribing patterns.
Members will also receive a monthly Explanation of Benefits (EOB) showing what medications were billed to Simply Healthcare under your account. Please review this information and call Member Services if there are any discrepancies.
Some prescription drugs require prior authorization (PA) or a medical exception for coverage. If your drug requires this step, your doctor will need to request and receive approval from Simply Healthcare before the drug may be covered under your benefit plan.
Why is Prior Authorization required?
Simply Healthcare requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from the plan before you fill your prescriptions, if you don't get approval, the plan may not cover the drug.
How do I get Prior Authorization for my prescription?
Follow the steps outlined below to receive coverage for medications requiring prior authorization:
- If a Prior Authorization is required, ask your doctor to submit the request to Simply Healthcare by fax (1-877-577-9045) or by phone (1-877-577-9044) and include a Request for Coverage Determination Form.
Request for Medicare Prescription Drug Coverage Determination (English / Spanish)
- Once your request has been processed, your doctor will be notified. The plan will mail you a determination notice.
Please use the links listed in this document to access the specific criteria set that applies to your plan.
What Are Organization Determinations (Part C)?
An organization determination is a decision made by us Simply Healthcare regarding:
You, your authorized representative or any provider who furnishes or intends to furnish services to you, may request an organization determination by filing a request with Simply Healthcare.
- Receipt of care or payment for care for a managed care item or service.
- The amount we require you to pay for an item or service; or
- A limit on the quantity of items or services.
How a Health Plan Processes Organization Determination Requests
Notification of determination will be provided within 72 hours for expedited organization determination requests. However, under certain circumstances, we can take up to an additional 14 calendar days.
If we need additional time to make the decision, we will tell you in writing.
Standard organization determinations decisions will be communicated within 14 calendar days. However, the plan can take an additional 14 calendar days if you ask for additional time, or if we need information that may benefit you.
Precertification Request Form
What if your Drugs have Quantity Limits?
For certain drugs, Simply Healthcare limits the amount of the drug it will cover. For example, Simply Healthcare provides 30 tablets per prescription for LIPITOR 10 MG TABLETS. This may be in addition to a standard one month or three month supply.
Access all of the quantity limits on Simply Healthcare Medicare Advantage Plan Part D prescription drugs.
What is Step Therapy?
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. If your drug has a step therapy requirement, we will need your doctor to request and receive approval from Simply Healthcare before the drug may be covered under your benefit plan.
Please use the links listed below to access the specific criteria set that applies to your plan.
You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have a medical reason that would justify asking the plan for an exception, your provider can help you request an exception to our utilization management tools; such as prior authorization, quantity limits, or step therapy requirements. You can ask the plan to cover a drug even though it is not on the plan's drug list, or you can ask the plan to cover the drug without restrictions.
What is an exception?
You or your doctor may ask the plan to make an exception to its Part D Coverage Rules in a number of circumstances, for example:
- Covering a Part D drug for you that is not on the plan's List of Covered Drugs (Formulary): called the “Drug List” for short. Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a formulary exception.
- Removing a restriction on the plan's coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on the plan's List of Covered Drugs (Formulary).
- Getting plan approval in advance before the plan will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
- Being required to try a different drug first before the plan will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)
- Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.
- Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.”
- If your drug is in a cost-sharing tier you think is too high, start by talking with your provider. Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you. You can call the Member Services Department to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you.
- Asking to pay a lower preferred price for a covered non-preferred drug is sometimes called asking for a “tiering exception.”