Safety and Quality Programs

Safety and Quality Programs

We have a set of rules, programs, and safety checks to keep you safe and control your drug costs. We call it utilization management.

Healthcare is often about finding the right balance — and that’s definitely true with prescription drugs. The right medication in the right dose can save your life. But get it wrong, and it can be very harmful.

Utilization management is a set of rules, programs, and safety checks with two goals in mind. First, we want to make sure you take medications that are safe for you — and that you take them in the most effective way. Second, we want to keep your drug costs down.

We worked with doctors and pharmacists to create our utilization management tools — you can read about them below. As always, if you have any questions, call us at 1-855-959-5855 TTY 711.

Prior Authorization (PA)

Before you get some drugs, you need prior authorization (PA). That means your provider has to check with us first to make sure we’ll cover them. This is one way we use to make sure you’re getting the right drug for you.

A list of drugs that require prior authorization and their criteria can be found here (2020), here (2021 HMO Gold), here (2021 HMO- SNP Bronze).

Quantity Limits (QL)

For certain drugs, you’re covered for only a limited amount of medicine — or for a set length of time. These are called quantity limits. For example, you might only be covered for 30 pills in one month. We use this for safety reasons and to control costs.

A list can be found here.

Step Therapy (ST)

Before you can get certain medications, you’ll first need to try one that costs less and has been proven to work for your condition. If the lower-cost drug doesn’t help you, then you can step up to the more expensive one.

A list of drugs that requires step therapy and their criteria can be found here (2020), here (2021 HMO Gold), here (2021 HMO- SNP Bronze)

Generics Before Brand Names

When a drug comes as both a generic and a brand name, our pharmacies will give you the generic one — unless your doctor says you need the brand name. This is another way to keep drug costs in check.

Drug Utilization Review

With Optum RX, our pharmacy partner, we do drug safety checks known as utilization reviews. Each time you fill a prescription — and sometimes in between — we check that:

  • You get the right medication and dose
  • You aren’t already taking a drug that treats the same condition
  • You don’t have a known allergy to the drug
  • The drug is safe for someone of your age and sex
  • The drug is safe to take with your other medications

If we find a problem, we work with your doctor to correct it.

Medication Therapy Management

When you have to take a number of drugs, it can be a challenge to keep it all straight. And safety becomes even more important. Medication Therapy Management is a program that can help.

Medication Therapy Management

Medications can play a key role in your healthcare. To get the most from them — and keep yourself safe — you need to know how to use them the right way. That’s not always as straightforward as it sounds. And it can be even harder when you need more than one drug.

That’s where our medication therapy management program can make a big difference. It doesn’t cost you anything, and it can help:

  • Limit or prevent harm that medications may cause
  • Make you more aware of how your medications improve your health — and what the risks and side effects are
  • Support healthy habits that keep you safe and help you get the most from your drugs

If you qualify for the program, you get two types of drug review: a comprehensive medication review and a targeted medication review. Read on to learn more.

How do I know if I qualify?

The program is open to you if all three of the following are true:

  1. You take 8 or more maintenance drugs covered by Medicare Part D
  2. You have 3 or more of these long-term health conditions:
    • Bone Disease-Arthritis-Osteoporosis
    • Bone Disease-Arthritis-Rheumatoid Arthritis
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia
    • Hypertension
    • Mental Health-Depression
    • Respiratory Disease-Asthma
    • Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
    • HIV/AIDS
  3. You and your Reliance plan together reach $4,255 in yearly prescription drug costs

If you meet all these conditions, we’ll sign you up automatically and send you a letter to let you know. You may also get a phone call to set up your first review.

Do I have to take part in the program?

No, you don’t. You can take part only if we invite you to (it’s not open to all members), but it’s your choice to take part or not. And whether you do or don’t, it won’t affect your coverage.

Comprehensive Medication Review

For this review, you’ll talk 1-on-1 with a pharmacist. They can answer your questions and talk about concerns you have about any of the medications you take, including:

  • Prescription drugs
  • Over-the-counter (OTC) medicines
  • Herbal therapies
  • Dietary supplements and vitamins

After the review, the pharmacist will send you a:

What will I get out of the review?

Different doctors may write prescriptions for you without knowing all the prescription drugs and OTC medications you take. The pharmacist will look at all of your medications across the board and:

  • Discuss how your prescription drugs and OTC medications may affect each other
  • Check if any prescription drugs and OTC medications may cause side effects — and offer suggestions to help
  • Help you get the most from all of your prescription drugs and OTC medications
  • Review ways to help you lower your prescription drug costs

The whole process can give you real peace of mind, knowing that you’re taking all your medications safely. And you might save some money.

Targeted Medication Review

This review happens behind the scenes. First, we take a look at the medications you’re taking. Then, we contact your doctor with suggestions about prescription drugs that may be safer — or work better — than your current drugs. We may also let you know about our suggestions.

You don’t have to make any changes — we’re just offering suggestions. It’s up to you and your doctor what to do with them.

How can I learn more?

If you have any questions — or if you don’t want to take part in the program after you’ve been signed up — just call us at 1-855-959-5855, TTY 711.

Last updated: 19 October, 2020 7:54 am

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