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Quality Assurance and Utilization Management

Plan Transition Process

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify members who take the drug that will be removed at least 60 days before the date the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer remove the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

Potential for Contract Termination

The Health Plan has contracts with Medicare and our provider networks to provide contracted services to eligible members in our service area. If any contract between Medicare or the provider organizations is altered for any reason, you will be notified of the change in a timely manner in accordance with Medicare regulations and provided with information on steps you should take to continue to receive Medicare services.

Drug Utilization Management

The Health Plan utilizes drug management programs to ensure certain drugs are used in the most effective manner and also to help control plan drug costs. These may include: prior authorization, quantity limits, step therapy, and generic substitution. We also conduct drug utilization reviews to make sure members are getting safe and appropriate care. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records.

  • Prior Authorization
    SecureCare (HMO), SecureCare SNP (HMO SNP), and SecureChoice (PPO) require you and your physician to get prior authorization for certain drugs. This means that you will need to get approval from SecureCare (HMO), SecureCare SNP (HMO SNP), or SecureChoice (PPO) before you fill your prescription.
  • Step Therapy
    In some cases, SecureCare (HMO), SecureCare SNP (HMO SNP), or SecureChoice (PPO) require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

If you would like information about the aggregate number of grievances, appeals, and exceptions filed with The Health Plan, please call our Customer Service at 1.877.847.7907 (TTY/TDD: 711).

Last Updated: 10/30/2017