What is Utilization Management?

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a higher cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost-sharing.

Examples of utilization management tools are described below:

  • Prior Authorization: Passport Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
  • Quantity Limits: For certain drugs, Passport Advantage limits the amount of the drug that we will cover. For example, Passport Advantage provides 18 tabs per prescription for sumatriptan tab. This may be in addition to a standard one month or three month supply.
  • Step Therapy: In some cases, Passport Advantage requires 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.

You can find out if your drug is subject to these additional requirements or limits by looking in our formulary (or drug list) located here. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. See the section, Part D Exceptions, Appeals, and Grievances for more information.


Drug Utilization Review and Quality Assurance

We conduct drug utilization reviews for all of our members to make sure that you are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe 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:

  • 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

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


Medication Therapy Management (MTM)

Click here to find information about the Passport Advantage Medication Therapy Management Program.



Last Modified: December 5, 2016