Quality Assurance
Utilization Management: For certain prescription drugs,
DeanCare Rx has additional requirements for coverage, or limits on 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 pharmacists developed these requirements and limits for DeanCare Rx to
help us to provide quality care to our members. Examples of utilization
management tools are:
Prior Authorization
DeanCare Rx requires you to get prior authorization for certain drugs. (you may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exception process.) This means that you will need to get approval from DeanCare Rx before you fill your prescriptions. If you don't get approval, DeanCare Rx may not cover the drug.
Quantity Limits
For certain drugs, DeanCare Rx limits the amount of the drug that DeanCare Rx will cover. For example, DeanCare Rx provides 9 tablets per prescription for IMITREX. This may be in addition to a standard 30 day or 90 day supply.
Step Therapy
In some cases, DeanCare Rx requires 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, DeanCare Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, DeanCare Rx will then cover Drug B.
Drug Utilization Review: DeanCare Rx conducts drug utilization reviews for all of our members to make sure that you are receiving 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, DeanCare Rx looks for medication problems such as:
If DeanCare Rx identifies a medication problem during utilization review, we will work with your doctor to correct the problem.
Medication Management Programs: DeanCare Rx offers medication management programs for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for DeanCare Rx by a team of pharmacists and doctors and are free to members that qualify. We use these medication management programs to help us provide better care for our members. For example, these programs help us to make sure that our members are using appropriate drugs to treat their medical conditions and help us to identify possible medication errors.
Medication Therapy Review: A health survey and a welcome letter will be sent to patients who qualify based on their drug history. After the survey is returned, a pharmacist will review the health survey and drug information. A call will be made to the patient to talk about their health histories and drugs. They may also talk about ways to save money on drugs and ways to manage their health better. The pharmacist may also share this information with the patient's physician. Members in the program will receive a phone call and/or information every 90 days. Patients that do not qualify for the program for free will be able to sign up for a fee.
Please see the Evidence of Coverage for more information about utilization management, drug utilization review and medication management programs.
2008
Prior Authorization
DeanCare Rx requires you to get prior authorization for certain drugs. (you may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exception process.) This means that you will need to get approval from DeanCare Rx before you fill your prescriptions. If you don't get approval, DeanCare Rx may not cover the drug.
Quantity Limits
For certain drugs, DeanCare Rx limits the amount of the drug that DeanCare Rx will cover. For example, DeanCare Rx provides 9 tablets per prescription for IMITREX. This may be in addition to a standard 30 day or 90 day supply.
Step Therapy
In some cases, DeanCare Rx requires 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, DeanCare Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, DeanCare Rx will then cover Drug B.
Drug Utilization Review: DeanCare Rx conducts drug utilization reviews for all of our members to make sure that you are receiving 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, DeanCare Rx looks for medication problems such as:
- Possible medication errors
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
- Drugs that are inappropriate because of your age or gender
- Possible harmful interactions between the drugs you are taking
- Drug allergies
- Drug dosage errors
If DeanCare Rx identifies a medication problem during utilization review, we will work with your doctor to correct the problem.
Medication Management Programs: DeanCare Rx offers medication management programs for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for DeanCare Rx by a team of pharmacists and doctors and are free to members that qualify. We use these medication management programs to help us provide better care for our members. For example, these programs help us to make sure that our members are using appropriate drugs to treat their medical conditions and help us to identify possible medication errors.
Medication Therapy Review: A health survey and a welcome letter will be sent to patients who qualify based on their drug history. After the survey is returned, a pharmacist will review the health survey and drug information. A call will be made to the patient to talk about their health histories and drugs. They may also talk about ways to save money on drugs and ways to manage their health better. The pharmacist may also share this information with the patient's physician. Members in the program will receive a phone call and/or information every 90 days. Patients that do not qualify for the program for free will be able to sign up for a fee.
Please see the Evidence of Coverage for more information about utilization management, drug utilization review and medication management programs.
2008
- View the 2008 Classic Evidence of Coverage
- View the 2008 Value Evidence of Coverage
- View the 2008 Enhanced Evidence of Coverage
S5954_3232_1107
Last Modified Date: 11/28/2007
