Quality Assurance & Utilization Management
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 also help us control drug plan costs. A team of
doctors and pharmacists developed the following requirements and limits for our plans to help us provide quality coverage to
our members:
- Prior Authorization: We require you to get prior authorization for certain drugs. This means that your doctor
will need to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug.
- Step Therapy:In some cases, we require you to first try certain drugs to treat your medical condition before we
will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
- 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 20, 5mg tablets per prescription for certain drugs.
- 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 the drug you take is subject to these additional requirements or limits by looking in the Drug Formulary.
If your drug is subject to one of these additional restrictions or limits, and your physician determines that you are not able
to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which
is a type of coverage determination).
Drug Utilization Review
We conduct drug utilization reviews for all of our members to make sure that they 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 Program
We offer a medication therapy management program, or MTMP, at no additional cost for members who qualify for the program.
To qualify for MTMP, you must have certain multiple medical conditions (for example heart disease, diabetes, high blood pressure,
high cholesterol, lung disease, or other specific conditions), take at least five Part D prescription drugs, and have high drug
costs. This program was developed by a team of pharmacists and doctors. The MTMP helps us provide better service and care for our
members. Our MTMP pharmacists will work with your doctor to help ensure that you are using appropriate drugs to treat your medical
conditions, and to look for ways to help you save money on your medicines (for example, by using lower cost generics).
If you are eligible to join the MTMP we will send you a letter with information about the program. The letter will also explain how
you can sign up to have an Essence MTMP pharmacist call you to talk about your medicines, and address any questions or concerns you might
have about them. If you receive a letter, we hope you will choose to participate in the MTMP so that we can help you manage your medicines.
Again, there is no cost to you to participate in the Essence MTMP.
The program is not considered a benefit. If you would like more information, please contact Essence Customer Service.