Part D Quality Assurance Policy and Procedure

Drug Utilization Review

We conduct drug utilization reviews for all of our participants to make sure that they are receiving safe and appropriate care. These reviews are especially important for participants who have more than one doctor prescribing their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records.

During these reviews, we look for medication problems, such as:

  • 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 allergy contraindications
  • Drug dosage errors or duration of drug therapy
  • Clinical abuse and misuse of medications
  • Over-utilization and under-utilization of medications

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Medication Therapy Management Program (MTMP)

Our MTM program is a FREE service that is offered by Elderplan FIDA Total Care for participants who meet our selected criteria described below. Please note that this program is not considered a benefit.

Under our MTM program, you will have access to the following free services:

  • A telephone consultation with a pharmacist to review your current prescriptions and over-the-counter medications – the pharmacist will call you to talk about any medication-related issues you may be experiencing and to create a specific medication action plan (MAP), that you can share with your doctor.
  • Each eligible MTM participant’s drug information is analyzed for potential drug-drug interactions, possible adverse effects of medications, or gaps in care. Every quarter, we automatically enroll qualified participants in the MTM program so they may begin receiving this extra support. Eligible MTM participants will receive a letter notifying them that they have been auto-enrolled into the MTM Program. As an MTM participant, you are also eligible to receive a comprehensive medication review (CMR). We will offer you CMR participation by mail and in some cases by phone. The CMR will give you the opportunity to review all of your current medications with a pharmacist. This is a one-on-one, conversation by phone that takes about 30 minutes. After completing the CMR, you will be mailed a personal medication list (PML) and a medication action plan (MAP). The PML will include your current prescription medications, over-the-counter medications and dietary and herbal supplements.

Advantages of the MTM Program include:

  • Ability to identify and reduce the chance for medication errors
  • More information about your current medication therapy
  • Opportunity to save money by reducing duplicative therapy and offering affordable formulary alternative availability if applicable
  • Chance to identify and educate you on the side effects of the drugs you are taking and discuss ways to reduce those effects

For more information about the MTM program and to schedule your free medication review with a pharmacist, please call the number on your MTM welcome letter. You can also call Elderplan FIDA Total Care Participant Services at 1-855-462-3167, 8 a.m. to 8 p.m., 7 days a week (TTY 711) for additional information.

Drug Management Programs

Utilization management

For certain formulary drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our participants use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits to help us to provide quality coverage to our participants:

  • Prior Authorization: We require you to get prior authorization for certain drugs. This means that providers will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug. See “Formulary Product Prior Authorization Approval Criteria” below.
  • 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. For example, we will provide up to 30 tablets per prescription for Pioglitazone tablets.
  • Step Therapy: In some cases, we require you to first try one drug 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 require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will 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 or writes “DAW” on the prescription.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary. If your drug is subject to one of these additional restrictions or limits and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

Drug Exclusions

While a Medicare Prescription Drug Plan can cover off-label uses of a prescription drug, we cover the off-label use only in cases where the use is supported by certain reference book citations. Congress specifically listed the reference books that list whether the off-label use would be permitted. These compendia are: (1) American Hospital Formulary Service Drug Information; (2) United States Pharmacopoeia-Drug Information; and (3) the DRUGDEX Information System; and (4) Medscape. If the use is not supported by one of these reference books (known as compendia), then the drug would be considered a non-Part D drug and would not be covered by Elderplan.