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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 Limits: 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: 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. See the section, “How do I request an exception to the formulary?” for more information.

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. 

Last Updated: 
October 1, 2017