Quality Assurance

What is Quality Assurance?

Our aim is a system of quality assurance that focuses on health care decision making and the health outcomes of Medicare beneficiaries, that enhances professional responsibility and capacity for improving care, that uses clinical practice as a source of information to improve quality, and that can be shown to improve the health of elderly people by attending to problems of overuse and underuse of services as well as poor technical quality.

Examples of quality assurance processes in relation to Medicare Part D may include the following:

Concurrent Drug Utilization Review

This occurs when a prescription is being filled at the pharmacy. Your prescriptions are reviewed for safety issues that may address the following:

  • Possible medication errors
  • Drug dosage and therapy duration errors
  • Duplicate drugs that are unnecessary because you are taking another to treat the same medical condition
  • Drug allergies
  • Possible harmful interactions between the drugs you are taking
  • Drugs that are not appropriate for your age or gender

Retrospective Drug Utilization Review

This occurs after a prescription is filled. This process reviews members' drug histories and identifies opportunities to improve the quality of care by identifying patterns of inappropriate or medically unnecessary therapy.

What Is Drug Utilization Management?

Drug utilization management programs are designed to improve quality and reduce costs when medically appropriate. The program includes systems to assist in preventing overuse and underuse of prescribed medications.

Examples of utilization management in relation to Medicare Part D may include the following:

Prior Authorizations

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.

Quantity Limits

For certain drugs, we limit the amount of the drug that you can have by limiting 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.

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, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

Use of Generic Drugs

Generally, a “generic” drug works the same as a brand name drug and usually costs less. In most cases, 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 neither the generic drug nor other covered drugs that treat the same condition will work for you, then we may cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)