How utilization management works for you
Utilization management (UM) helps ensure you get the right drugs while making medicine more affordable.
Utilization management is made up of several different components:
- Prior authorization means that your health plan needs to approve your medicine before it is covered. Learn more about our Prior Authorization Criteria and Guidelines.
- Step therapy uses a “step” approach to drugs for certain conditions. This means you may have to first try a safe, lower-cost drug or one that may be more clinically effective before “stepping up” to a different one.
- Quantity limits control how often or the amount you can get filled at once. These limits are in place to promote safe, cost-effective drug use, ensuring that you receive the right amount of medication for your needs and helping to reduce waste and overuse.
- Drug Utilization Reviews ensure all of our members receive safe and appropriate care. These reviews are especially important for members with more than one doctor prescribing their medications. We conduct drug utilization reviews each time you fill a prescription. During these reviews, we look for medication problems, such as:
- Duplicate prescription drugs that are unnecessary because you are taking another medicine to treat the same medical condition
- Prescription drugs that may be inappropriate because of your age or gender
- Possible harmful interactions between drugs you are taking
- Prescription drug allergy contraindications
- Dosage errors or duration of prescription drug therapy
- 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. See more information on Prior Authorization.
