Quality Assurance

Avoiding Problems with Your Prescribed Medicines
We conduct Drug Utilization Reviews (DUR) for our members. These reviews are especially important for members with more than one doctor prescribing their medications.

Each time you fill a prescription, we check:

• possible medication or dosage errors
• possible harmful interactions
• drug allergies
• duplication of drugs
• drugs that are inappropriate because of your age or gender.

How the DUR System Works
Your pharmacist enters your prescription online, where it is reviewed against all your previous prescriptions from the various pharmacies that are in the system. If we identify a potential medication problem, we will discuss it with your pharmacist and/or doctor to correct the problem. Your pharmacist or doctor may also call you.

The following checks are completed online, in 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
• drug age/gender interaction
• drug-pregnancy interaction

Helping Your Doctor(s) Manage Your Medicines
We may notify physicians about potential problems with certain drugs. A targeted drug utilization review helps identify members who may be:

• receiving improper medicines or high doses;
• getting the wrong combinations of products;
• abusing narcotics.

Addressing the Increasing Cost of Drugs
A team of doctors and pharmacists developed requirements and limits on certain drugs to help the plan manage drug usage. The idea of utilization management is to continue to provide access to prescription drugs you need, while keeping plan costs down.

How utilization management may affect you:

• Prior Authorization. This means that physicians will need to get approval from us before you fill your prescription for certain drugs. If they don’t get approval, we may not cover 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 provider writes “no substitutions” on the script.
• Step Therapy. This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

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