Part D Quality Assurance
Drug Exclusions
Drug Management Programs
Medication Therapy Management (MTM) Program
What is the medication therapy management (MTM) program?
How does it work?
How can the program help the participant?
Who is eligible for the program?
How long does the program last?
Formulary Prior Authorization Approval Criteria
Drug utilization review
By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plans. These drugs are not considered Part D drugs and may be referred to as “exclusions” or “non-Part D drugs.” These drugs include:
- Nonprescription drugs
- Drugs when used for anorexia, weight loss or weight gain
- Drugs when used to promote fertility
- Drugs when used for cosmetic purposes or hair growth
- Drugs when used for the symptomatic relief of cough or colds
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
- Barbiturates and benzodiazepines
- Drugs when used for the treatment of sexual or erectile dysfunction
NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra and Caverject starting January 1, 2007. Call for more information.
In addition, a Medicare Prescription Drug Plan cannot cover a drug that would be covered under Medicare Part A or Part B.
Also, while a Medicare Prescription Drug Plan can cover off-label uses of a prescription drug, we cover the off-label use only in cases where the use is supported by certain reference book citations. Congress specifically listed the reference books that list whether the off-label use would be permitted. These compendia are: (1) American Hospital Formulary Service Drug Information; (2) United States Pharmacopoeia-Drug Information; and (3) the DRUGDEX Information System; and (4) Medscape. If the use is not supported by one of these reference books (known as compendia), then the drug would be considered a non-Part D drug and would not be covered by Elderplan.
Utilization management
For certain formulary 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 pharmacists developed the following requirements and limits to help us to provide quality coverage to our members:
- Prior Authorization: We require you to get prior authorization for certain drugs. This means that providers will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug. See “Formulary Product Prior Authorization Approval Criteria” below.
- 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. For example, we will provide up to six tablets per prescription for Imitrex tablets.
- Step Therapy: 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.
- 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 or writes “DAW” on the prescription.
You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary. 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 can request an exception (which is a type of coverage determination).
Medication Therapy Management (MTM) Program
Our MTM program is a FREE program that is offered by Elderplan for members who meet our selected criteria described below. Please note that this program is not considered a benefit.
Under our Medication Therapy Management, or MTM, you will have access to the following free services:
- A telephonic consultation with a pharmacist to review your current prescriptions and over-the-counter medications- The pharmacist will call you to talk about any medication-related issues you may be experiencing and to create a specific medication action plan, or MAP that you can share with your doctor.
- Ongoing comprehensive medication review- Elderplan, in consultation with your doctor, will review your medications on a regular basis to ensure that your medication action plan remains current.
Advantages of the MTM Program include:
- Identify and reduce the chance for medication errors
- More information about your current medication therapy
- Opportunity to save money by reducing duplicative therapy and offering affordable formulary alternative availability if applicable
- Identifying and educating you on the side effects of the drugs you are taking and discussing ways to reduce those effects.
For more information about the MTM Program and to schedule your free medication review with a pharmacist, please call the number on your MTM welcome letter. MTM welcome letter is sent to you if you qualify for the program. You can also call Elderplan Member Services at 800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220) for additional information.
What is the medication therapy management (MTM) program?
The MTM program is designed to help our Elderplan members deal with multiple medications and illnesses. This program is another way to help you get the safest, most effective and affordable prescription drugs. Our staff works with individual members and their health care providers to be a source of information and support for medication management.
How does it work?
Once you are selected for MTM program, you will receive a welcome letter from our MTM vendor and information about MTM. Our MTM vendor will contact you to schedule a telephone consultation with a pharmacist. Pharmacist will conduct a comprehensive medication review to identify any potential medication related issues. If any medication issue is identified during the telephonic consultation with a pharmacist, we will discuss it with your provider. Participation in this program is voluntary. You can contact Elderplan Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220) to opt-out of the program.
How can the program help the participant?
Our licensed pharmacists will assist you by being a source of knowledge about prescription and over-the-counter drugs. We can answer questions you may have about your medications and discuss potential drug therapies with your providers. Overall, our goal is to make sure you are getting and taking the types of medication that are right for you.
Who is eligible for the program?
Eligible participants are those members with Medicare Part D prescription coverage who take at least 8 (eight) Part D drugs and spend more than $750 per quarter on Part D medications. Participants of the program also have at least 3 of the below mentioned diseases of the following conditions (condition overviews are provided on the other page):
- Diabetes
- Hyperlipidemia (high cholesterol)
- Hypertension (high blood pressure)
- Osteoporosis
You are not required to participate in this program, if you do not wish to do so. You can contact Elderplan Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220) to opt-out.
How long does the program last?
The program runs from the time that the member meets eligibility requirements until the end of the calendar year. You may be re-enrolled in the program the following January if you want to participate in the program and you continue to meet the requirements for the new contract year. Rev. 11.29.10. ef
Formulary Prior Authorization Approval Criteria
Certain drugs need authorization from Elderplan prior to dispensing at the pharmacy. Please click on the Prior Authorization Approval List link to see if you meet the criteria to receive authorization for your drug. You can also go to the Searchable Formulary to see if your drug needs prior authorization. If you have any questions regarding prior authorizations, call our pharmacy benefit manager at 1-800-361-4542 or Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220).
Drug utilization review
We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor prescribing 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:
- 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 allergy contraindications
- Drug dosage errors or duration of drug therapy
- Clinical abuse and misuse of medications
- Over-utilization and under-utilization of medications
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
