PART D UTILIZATION MANAGEMENT

Products within our OTC or Over the Counter Benefit (Part C) are not part of a Utilization Management (Part D) program.

Products purchased under Part D such as syringes and alcohol wipes are not available under a Part C programs such as our OTC or Over the Counter Benefit. Many independent as well as chain pharmacies such as Walgreens and Rite Aid participate in this program but not all. Please call (800) 499-2793 to find a participating store.

CareMore has a number of Quality Assurance and Utilization Management Initiatives designed to improve quality, prevent over and under utilization and reduce costs. These programs include but are not limited to Medication Therapy Management, Healthy Start, Concurrent Drug Utilization Review and Retrospective Drug Utilization.

 

MEDICATION THERAPY MANAGEMENT

For eligible members, our Medication Therapy Management Program (MTMP) is designed to optimize therapeutic outcomes. The program provides education on medication safety and addresses issues of adverse drug events and interactions. In addition, suggestions are made for formulary alternatives to reduce patient's co-pay burden.

To be eligible, members have to meet the following criteria:

• Have two or more of the following conditions: Diabetes, Hypertension, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and End Stage Renal Disease (ESRD).
• Take 5 or more Part D, disease-specific drugs related to above chronic diseases.
• Incur an expected annual cost for Part D drugs to exceed $3000.

This program was developed in cooperation with licensed and practicing pharmacists. A pharmacist will review member’s medication profile and recommendations will be forwarded to the member’s physician. This program is provided to all qualified members at no cost. Please contact the CareMore's Member Services at (800) 499-2793 for additional information.

This program is not considered a benefit.

 

HEALTHY START PROGRAM

As a new member, you are encouraged to schedule a Healthy Start appointment at one of our CareMore Care Centers as soon as you enroll into one of our health plans. At the Healthy Start appointment, you will receive a personalized comprehensive medical assessment performed by one of our specially trained nurse practitioner and/or physician. Your new care team will make specific recommendations that are tailored to you and are presented in a personalized care plan. The care plan will provide a summary of your health, medical and social needs as well as proactive recommendations for follow-up care. This information will also be shared with your Primary Care Physician.

The Healthy Start Program includes:

• Head to toe comprehensive medical assessment

• Evaluation of your medications

• Personalized care plan

• On-site lab results

• Referrals for other CareMore programs and necessary services

This program is considered a benefit.

 

CONCURRENT DRUG REVIEW

CareMore has policies and procedures designed to ensure that a review of the prescribed drugs is performed at the point of sale or distribution before a prescription is dispensed to a member. CareMore, through its Pharmacy Benefits Manager National Pharmaceutical Services, promotes appropriate dispensing and use of drugs to ensure high quality of care and cost-effective therapy.

On-line reviews or edits include but are not limited to:

• Duplicate Drug Class

• Drug Age/Gender Edit

• Drug/Drug Interaction

• Drug-to-Disease Contraindication

• Drug Allergy

This program is not considered a benefit.

 

RETROSPECTIVE DRUG UTILIZATION

CareMore utilizes retrospective Drug Utilization Review (DUR). The Drug Utilization Review (DUR) is designed to ensure ongoing periodic examination of claims data and other records through a computerized drug claims processing and information retrieval system. The system identifies patterns of inappropriate or medically unnecessary associated with the use of specific drugs or groups of drugs.

These DUR reviews include but are not limited to the following:

• BEERS Criteria Reports (or HEDIS) for indicators of drugs to be avoided in the elderly

• Specific medication reports on the use of Statins, PPIs and multiple narcotics (alternative recommendations provided)

• Physician utilization reports that identify over/under utilization, patterns of prescribing, poly-pharmacy patients and generic utilization (ways to improve costs provided)

This program is not considered a benefit.