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Easy Choice Health Plan Drug Management Program
2017 Benefit Year
Utilization managementFor 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:
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.
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 30 tablets per 30-day period for Aripiprazole.
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.
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* page 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 Evidence of Coverage for more information about how to request an exception.
*The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Drug Utilization ReviewWe 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:
- Drugs that are inappropriate because of your age or gender
- Possible harmful interactions between drugs you are taking
- 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 ProgramThe Medication Therapy Management (MTM) program (MTM Program) is required by the Centers for Medicaid and Medicare Services (CMS) for all Part D Prescription Drug Plans (PDP) and Medicare Advantage Plans (MA). The program is not considered a benefit, but rather a free service offered to those who are eligible and qualify for the program. There is no change to your insurance benefits, co-pays, prescription coverage, or available doctors or pharmacies.
The 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:
- You take eight or more Medicare Part D covered maintenance drugs, and
- You have three or more of these long term health conditions:
- Chronic Heart Failure
- Cardiovascular Disorders such as High Blood Pressure, High Cholesterol, or Coronary Artery Disease and
- 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 [PDF, 84KB] for tracking your prescription
Targeted Medication Review (TMR).
A TMR is where 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 1-844-635-3406, 24 hours a day, 7 days a week. TTY users call 711.
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