Quality Assurance

Drug Utilization

The Pharmacy Benefits Manger (PBM) is responsible for pre-dispensing drug utilization review (DUR) edit checks, which are performed on an online, real-time basis at mail-order and retail network pharmacies. All prescriptions are compared against previous prescriptions filled by the same pharmacy, by other participating retail network pharmacies, and by the mail service pharmacy. All drug interactions are detected online when each prescription is entered into the pharmacy’s system. If an interaction is identified, the pharmacist will review the patient history and may contact the prescribing physician prior to filling the prescription.

The drug utilization review activities are an integral component of our overall commitment to safety and quality. Alerting the pharmacy to potential drug interactions and/or duplicate therapies and discussing these potential problems with the prescribing physician(s) ensures that the correct amount of the appropriate drug is being delivered. These procedures allow the pharmacist to override the alert once the pharmacist has reviewed the data with the patient and/or physician and has determined that the prescription is safe to dispense.

The following edit checks are completed online, real-time as a prescription is being dispensed:

duplicate drug therapy
too-early refill
low-dose/high-dose alert
incorrect daily dosage
excessive or questionable days’ supply
drug-to-drug interaction
age/gender interaction
pregnancy interaction

In addition, physicians can be notified of these interactions or other clinical issues on a retrospective basis. The targeted DUR can be implemented to identify members who may be receiving improper doses or combinations of products, who may potentially be abusing narcotics, and who are receiving high doses of medication. An automated check of drug claims data is performed to identify potentially inappropriate prescriptions for individual members. If the computer program finds that, based on a member’s current medications, a particular prescription may have violated the criteria for optimal drug use, an advisory letter is sent to the prescribing physician(s) for further review.

Utilization Management

For 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 help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our plan to help us to provide quality coverage to our members.

Examples of utilization management tools are described below:

Prior Authorization
We require you to get prior authorization for certain drugs. This means that physicians will need to get approval from us before you fill your prescription. If they do not get approval, you may still obtain the drug, but we may not cover the cost of the drug.
Quantity Limits
For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
Generic Substitution
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 have obtained a prior authorization.

You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. See Exceptions and Appeals for more information.

Drug utilization review

We 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 prescribes 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:

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 drugs you are taking;
drug allergies;
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 (MTM) Program

We offer a medication therapy management program at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. This program was developed for us by a team of pharmacists and doctors. We use this program to help us provide better coverage for our members. For example, it helps us make sure that our members are using appropriate drugs to treat their medical conditions and also helps us identify possible medication errors.

We offer the medication therapy management program for members that meet specific criteria. We may contact members who qualify for these programs. If we contact you, we hope you will enroll so that we can help you manage your medications. Remember, you do not need to pay anything extra to participate. If you accept enrollment into a medication therapy management program we will send you detailed information what you can expect from the program.

This program may have limited eligibility criteria. To be eligible, members must meet one or more of the following conditions:

at least two of the following disease states: hepatitis C, anemia, rheumatoid arthritis, metabolic syndrome, chronic pain, asthma, COPD;
at least two medications used to treat the above conditions;
likely to incur at least $4,000 in drug costs per year.

For more information, contact Customer Service.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions.

Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor AmeriHealth 65 NJ HMO will be responsible for the costs.

Please contact AmeriHealth 65 HMO for more information.

In lots of cases, your prescriptions are covered under AmeriHealth 65 NJ HMO, AmeriHealth Rx PDP if they are filled at a network pharmacy or through our mail-order pharmacy service. There are thousands of network pharmacies, including:

national chain and independent retail pharmacies
long-term care and home-infusion pharmacies
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies

Website last updated: 12/30/11
Y0041_HNS_12_301a Pending CMS Approval