Part D

Medication Therapy Management (MTM) Program

We offer a full range of pharmacy services to members at high-risk for medication related problems. The Care1st MTM program is offered at no additional cost. Members who meet certain criteria (multiple medical conditions, taking many prescription drugs, and will most likely incur high drug annual cost), may qualify for the program. The goal of the program is to provide an integrated approach that results in effective and safe medication treatments that lead to positive outcomes. This program helps us make sure that our members are using the appropriate drugs to treat their medical conditions and helps us identify possible medication problems. This is a voluntary program. If you are selected, we will send you information about the specific program.

Quality Assurance

We have established measures and systems to conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. The programs include real-time and historic review of prescriptions claims to reduce medications errors and adverse drug interactions. These reviews are especially important for members who have more than one doctor who prescribe their medications, use more than one drug, or have more than one pharmacy.

Care1st conducts drug utilization reviews when your pharmacy fills your prescription at the point-of-sale. The claim may be electronically reviewed for the following:

  • Screen for duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
  • Age-related contraindications
  • Gender-related contraindications
  • Drug-Drug interactions
  • Incorrect drug dosage
  • Incorrect duration of therapy
  • Clinical abuse or misuse

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Utilization Management

This program incorporates utilization management tools to encourage appropriate and cost-effective use of Part D medications. A team of doctors and pharmacists developed these requirements and limits to help us provide quality coverage to our members. These tools include‚ but are not limited to: prior authorization‚ clinical edits‚ quantity limits and step therapy.

  • Age Limits: Some drugs may require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.
  • Quantity Limits: For certain drugs, we limit the amount of the drug we will cover per prescription or for a defined period of time.
  • Prior Authorization: We require you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don't get approval, Care1st may not cover the drug.
  • Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
  • 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 doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher copay and/or the difference in cost between the brand and generic medications.

You can find out if your drug is subject to any one of these tools by looking in the Care1st pharmacy formulary.

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