At MoreCare, we offer programs like Drug Utilization Reviews and Drug Utilization Management at no extra cost to our Part D members. The goal of these programs is to prioritize the health and safety of our members by encouraging safe and appropriate use of prescriptions drugs covered under Medicare Part D. These programs help us identify potential risks and opportunities to prevent medication errors and provide optimal drug therapy.
Drug Utilization Reviews
This program reviews the following each time a prescription is dispensed. If we identify any issues with your drug therapy, we work with your provider to correct the problem.
- Possible medication errors
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
- Drugs that are inappropriate because of your age or gender
- Possible harmful interactions between drugs you are taking
- Drug allergies
- Drug dosage errors
Drug Utilization Management (or Coverage Rules)
This program is designed to require approval from the plan for certain prescription drugs on our formulary (or drug list). In some way these drugs may have additional requirements for coverage to ensure safe, appropriate and cost-effective use of Medicare Part D prescription drugs. You can find out if your drug is subject to these restrictions by checking our coverage and drug pricing tool online.
There are three types of drug coverage rules that may apply:
- Prior Authorization (PA): If a drug you take or want to take requires you to get prior approval, it means you or your doctor need to get approval from the plan by meeting specific criteria before your drug is covered. PA Criteria
- Quantity Limits (QL): For certain drugs, we may limit the amount of the drug that we will cover each time you fill a prescription. If it is considered safe to take one pill per day for a certain drug, then we will cover only up to that allowed quantity per day for allowed duration of time. No coverage request is needed if within quantity limits. For example, 30 tablets per prescription for Drug A every 30 days because it is considered safe.
- Step Therapy (ST): In some cases, we require you to first try a less costly drug that is as equally effective as the one you are requesting coverage for. If the Drug A is not effective in treating your condition, then we will cover Drug B which is also used to treat the same medical condition as prescribed by your doctor. For example, we will not initially cover Drug B unless you have tried and failed an equally effective and a less costly drug first for treating the same medical condition. ST Criteria
Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Medicare Part D plan.