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DRUG MANAGEMENT PROGRAMS

Utilization Management | Utilization Review | Medication Therapy Management

Utilization Management

For certain prescription drugs, special rules restrict how and when the Plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

GlobalHealth uses different types of restrictions to help our members use drugs in the most effective ways:

  • Restricting brand name drugs when a generic version is available - Generally, a “generic” drug works the same as a brand name drug and usually costs less. When a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that the generic drug will not work for you OR has told us the medical reason that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug).
  • Getting Plan Approval in Advance - For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called "prior authorization." Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. Click here for our 2017 prior authorization criteria.
  • Try a Different Drug First - This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "step therapy." Click here for a list of 2017 drugs requiring step therapy.
  • Quantity Limits - For certain drugs, we limit the amount of the drug that you can have. For example, the plan might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.

The 2017 GlobalHealth Drug Formulary includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug Formulary. For the most up-to-date information, call Customer Care at (866) 494-3927 (TTY 711), 24 hours per day, 7 days per week.

Utilization Review

The CVS Health team completes medication reviews for our plan enrollees to evaluate safety and appropriateness of their drug therapy. The automated database and pharmacy staff reviews provide important clinical information to members that see multiple prescribers for their medications. The utilization reviews are completed each time a prescription is filled by the enrollee. We also review our records on a regular basis. During these, reviews, we look for potential problems such as:

  • Possible medication errors
  • Drugs that may not be necessary because you are taking another drug to treat the same medical condition
  • Drugs that may not be safe or appropriate because of your age or gender
  • Certain combinations of drugs that could harm you if taken at the same time
  • Prescriptions written for drugs that have ingredients you are allergic to
  • Possible errors in the amount (dosage) of a drug you are taking

When potential drug therapy conflicts are noted, clinical information describing the conflict is sent to your prescriber for their evaluation and follow-up, based on their professional judgment and clinical knowledge of the enrollee’s medical condition.

Medication Therapy Management Program (MTM)

The Medication Therapy Management (MTM) program helps you get the greatest health benefit from your medications by:

  • Preventing or reducing drug-related risks
  • Increasing your awareness
  • Supporting good habits

Who qualifies for the MTM Program?

We will automatically enroll you in the Medication Therapy Management Program at no cost to you if all three (3) conditions apply:

  1. You take eight or more Medicare Part D covered maintenance drugs, and
  2. You have three or more of these long term health conditions:
    • Asthma
    • COPD
    • Diabetes
    • Depression
    • Osteoporosis
    • Chronic Heart Failure
    • Cardiovascular Disorders such as High Blood Pressure, High Cholesterol, or Coronary Artery Disease
    --and--
  3. You reach $3,919 in yearly prescription drug costs paid by you and the plan.

Your participation is voluntary, and does not affect your coverage. This program is free of charge and is open only to those who are invited to participate. The MTM program is not considered a benefit for all members.

What services are included in the Medication Therapy Management Program (MTM Program)?

The MTM Program provides you with a:
Comprehensive Medication Review (CMR), and a
Targeted Medication Review (TMR)

Comprehensive Medication Review (CMR).
A CMR is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

  • Prescription drugs
  • Over-the-counter (OTC) medicines
  • Herbal therapies
  • Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the drugs you take. If more information is needed, the pharmacist may contact your prescribing doctor. A CMR review takes about 30 minutes and usually offered once each year if you qualify. At the end of your discussion, the pharmacist will give you a Personal Medication List of the medications you discussed during your CMR.

You will also receive a Medication Action Plan. Your plan may include suggestions from the pharmacist for you and your doctor to discuss during your next doctor visit.

Here is a blank copy of the Personal Medication List for tracking your prescriptions.

Targeted Medication Review (TMR).
With a TMR, we mail or fax suggestions to your doctor every three months about prescription drugs that may be safer, or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them.

How will I know if I qualify for the Medication Therapy Management Program (MTM Program)?

If you qualify, we will mail you a letter letting you know that you qualify for the MTM program. Afterward, you may receive a call from a partner pharmacy, inviting you to schedule a one-on-one medication review at a convenient time.

Will the Medication Therapy Management Program (MTM Program) pharmacist be calling from my regular pharmacy?

Yes, the MTM program pharmacist may be calling from your regular pharmacy if your regular pharmacy chooses to participate in the MTM Program as a service provider. You will be given the option to choose an in-person review or a phone review.

If your regular pharmacy does not participate in the program, you may be contacted by a Call Center pharmacist to provide your MTM review, and ensure that you have access to the service if you want to participate. These reviews are conducted by phone.

Why is a review with a pharmacist important?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

  • Discuss how your prescription drugs and OTC medications may affect each other.
  • Identify any prescription drugs and OTC medications that may cause side effects, and offer suggestions to help.
  • Help you get the most benefit from all of your prescription drugs and OTC medications.
  • Review opportunities to help you reduce your prescription drug costs.

How do I benefit from talking with a pharmacist?

  • Discussing your medications can result in real peace of mind knowing that you are taking your prescription drugs and OTC medications safely.
  • The pharmacy can look for ways to help you save money on your out-of-pocket prescription drug costs.
  • You benefit by having a Personal Medication List to keep and share with your doctors and health care providers.

How can I get more information about the Medication Therapy Management Program (MTM Program)?

Please contact us if you would like additional information about our MTM Program, or if you do not want to participate after being enrolled in the program. Our toll free number is (866) 494-3927, 24 hours a day, 7 days a week. TTY users call 711.