EASY CHOICE HEALTH PLAN (HMO)'S DRUG MANAGEMENT PROGRAMS
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/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members.
The requirements for coverage or limits on certain drugs are listed as follows:
Prior Authorization: We require you to get prior authorization (prior approval) for certain drugs. This means that authorized prescribers will need to get approval from us before you fill your prescription. If they do not get approval, we may not cover 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 62 capsules per 30-day period for Celebrex.
Step Therapy: In some cases, we require you to first try one drug 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 require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover 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 and we have approved this request.
You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary on our formulary Web site or by calling Customer Services. 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 may request an exception (which is a type of coverage determination). See Section 9 of the Explanation of Coverage for more information about how to request an exception.
Drug Utilization Review
We conduct drug utilization reviews for all of our members to make sure that they are getting 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 Programs (MTMP)
What Is MTMP?
Easy Choice Health Plan (HMO) Medication Therapy Management (MTMP) is a program that enables us to provide better coverage for our members by helping to ensure that our members are using appropriate drugs to treat their medical conditions and to identify possible medication errors and potential economic value.
What Are The Qualifications?
We offer medication therapy management programs at no additional cost to members who have a minimum of 2 chronic conditions (e.g: Bone Disease-Arthritis-Rheumatoid Arthritis, Chronic Heart Failure, Diabetes mellitus, Dyslipidemia, Chronic Heart Disease), who are taking 2 or more disease specific prescriptions, and who have incurred a Part D drug cost for $750.00 per quarter. This is a voluntary program. If the member elects to be part of the program, he/she work with a team of health professionals to ensure that medications are appropriate for the treatment of specific conditions and are taken as prescribed.
How Does The Program Work?
If you are selected to join a medication therapy management program we will send you information about the specific program, including information about how to access the program. Your enrollment in this Plan does not affect Medicare coverage for drugs covered under Medicare Part A or Part B. Once a member is accepted into the Program, a Care Plan is established which addresses the member’s health care needs and medications taken. Provisions of the Care Plan may include letters or other reminders to refill prescriptions; educational materials about one’s disease and/or action of the medications; phone calls with the nurse and/or pharmacist to review the medications taken; and, regular appointments with the prescribing physician.
For additional information, contact the Medical Management department at (866) 999-3945.