Utilization Management

There are restrictions on coverage for some drugs
There are special rules about how and when we will cover some prescription drugs. A team of doctors and pharmacists developed these rules. They help our members use drugs in the most effective ways. These rules also help control overall drug costs. This 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. The plan's rules are designed to encourage you and your health care provider to use lower-cost drugs when they will work medically just as well for you as a higher-cost drug

Using generic drugs whenever you can
A "generic" drug works the same as a brand name drug, but usually costs less. Our network pharmacies must provide you with a generic version of a brand name drug when one is available. However, if your health care provider gives us a medical reason that the generic drug will not work for you, then we will cover the brand name drug.

Getting plan approval in advance
For certain drugs, you or your health care provider need to get approval from us before we will cover the drug for you. This is called "prior authorization."

Trying a different drug first
This requirement encourages you to try safer or more effective drugs before we cover another drug. For example, if Drug A and Drug B treat the same medical condition, we may require you to try Drug A first. If Drug A does not work for you, we will then cover Drug B. This requirement to try a different drug first is called "step therapy."

Quantity limits
For certain drugs, we limit the amount of the drug that you can have. For example, we 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 1 pill per day for a certain drug, we may limit coverage for your prescription to no more than 1 pill per day.

Utilization Management programs for members of Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Senior Care Plus (MSC+), and Special Needs BasicCare (SNBC)

Utilization Management programs for members of PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP)

Formulary Exceptions
If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can Appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Please see your Evidence of Coverage for more information about the formulary exception process