Drug Quality Assurance
Our plan has Drug Quality Assurance programs to help you receive safe and timely care.
We provide these programs to improve how you take your drugs and to reduce errors and adverse reactions. These measures also ensure that your provider complies with pharmacy practice standards.
Getting your prescribed drugs filled on time and taking them as your doctor directs is an important part of staying healthy. Not taking your drugs on time can cause your health to get worse. There are some easy ways we can help you stay on track and feeling well.
- Ask your pharmacy if they offer 90-day refills or home delivery to save you time.
- Check with your pharmacy about auto refills to remind you when your order is ready.
- Save trips to the pharmacy by having all your drugs filled on the same day.
- For drugs you take regularly, sign up for our mail order service to ship orders to your home.
- Use a pill box and keep it handy to remind you to take your drugs on time.
If you need help getting your drugs and keeping them organized, please contact Member Services.
Drug Utilization Review Program
Our Drug Utilization Review Program includes a review of current and past claims. When a pharmacy submits your prescription for coverage, we look for:
- Age related issues
- Gender related issues
- Overuse and underuse
- Issues with other drugs you take
- Issues with a disease you have
- Wrong drug dosage
- Wrong length of therapy
- Drug/allergy issues
- Abuse or misuse
Based on this review, you, your doctor, and your pharmacy can make the most beneficial decision regarding your care.
For more information or questions about our DUR program, please contact Member Services.
Drug Management Program
Our Drug Management Program monitors our members' safe and effective use of opioid drugs like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine.
Taking opioid drugs can help with certain types of pain after an injury or surgery. Taking them also comes with serious risks like addiction, overdose and death. These risks can increase if you take high doses or take opioids with certain other drugs like benzodiazepines (Xanax®, Valium®, Klonopin®) for anxiety or sleep.
The program's goal is to help you, your doctor and your pharmacy ensure that you are prescribed the correct drugs for pain, and you take them safely.
When you fill a prescription, your pharmacist will review all the drugs that you take to check for:
- Potentially unsafe amounts
- Interactions with other drugs like benzodiazepines
A new prescription may be limited to a seven-day supply or less. This limit does not apply if you have been taking an opioid.
If your prescription can't be filled, your pharmacy will give you a notice explaining how to ask us for a coverage decision. If your health requires it, you can ask us for a fast coverage decision. You also can ask us for an exception to our rules before you go to the pharmacy so you'll know if we will cover your drug.
How our program works
If you get an opioid drug from more than one doctor, we may talk with your doctors to make sure you need the drug and that you’re using it safely. If we decide your use of the drug isn’t safe, we may limit your coverage. For example, to better coordinate your care, we may require you to get the drug only from certain doctors or fill them at certain pharmacies.
Before we place you in our program, we will send you a letter to explain our review of your drug history. You then can tell us which doctors or pharmacies you prefer to use to get your drugs. If we limit your coverage, we will send you another letter to explain what you and your doctor can do to appeal our decision.
Our program does not apply to you if you have cancer, sickle cell disease, or if you receive hospice, palliative or end-of-life care, or if you live in a long-term care facility.
Your provider can help
Talk with your doctor about all of your pain treatment options. Then decide what is right for you. You could take other drugs or do other things to manage your pain with less risk.
Contact Member Services if you have questions about our Drug Management Program.
For more information on safe and effective pain management visit:
- The Centers for Disease Control and Prevention (CDC) website at CDC Information for Patients or CDC Understanding the Epidemic.
- The U.S. Department of Health and Human Services website at HHS.gov Opioids.
- The Medicare.gov website, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Get information 24 hours a day, 7 days a week.
- Employer Plans - Medicare
- Drug and Pharmacy Information
- List of Drugs (Formulary) and Drug Change Notices
- Find a Pharmacy
- Drug Transition Policy
- Prior Authorization, Step Therapy and Quantity Limits
- Drug Coverage Determinations (exceptions) and Redeterminations (appeals)
- Medication Therapy Management Program (MTMP)
- Drug Quality Assurance
- Mail Order Service
- Specialty Pharmacy
- Out-of-Network Pharmacies