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Quality Assurance and Drug Management Programs

 

Utilization Management

 

For certain prescription drugs, we've placed some additional limits on coverage. These limits ensure our members use medications in ways that are most helpful. The limits also help us control your drug costs. Here are some examples of these utilization management tools:
 

Prior Authorization

For certain drugs, you’ll need to get prior authorization. This means your doctor needs our approval before you're able to fill some prescriptions. If your doctor doesn't get approval, we may not cover the drug.
 

Quantity Limits

For certain drugs, we limit the amount of the drug that we’ll cover or the length of time we’ll cover it. For example, we'll cover a maximum of 1 tablet per day of rosuvastatin.
 

Step Therapy

In some cases, your doctor will need to prescribe a certain medication instead of another to treat your condition(s). However, if the medicine proves less effective, we’ll then cover the other drug to treat your condition(s).
 

Generic Substitution

When both a generic and a brand-name drug are available, our network pharmacies will automatically provide you with generics, unless otherwise requested by your doctor. To find out which brand-name drugs would be approved, check our formulary. If the drug is not covered, you can request that we make an exception to our coverage rules.
 

Drug Utilization Review

Through CVS Caremark, we conduct prescription drug reviews for all members to make sure you’re safe. These reviews are especially important for members who have more than one doctor prescribing medications. We review your records on a regular basis. During these reviews, we look for possible medication problems such as:
 

  • Medication errors
  • Duplicate drugs (because you're taking another drug to treat the same medical condition)
  • Drugs that are not ideal because of your age or gender
  • Possible negative interactions between drugs you're taking
  • Drug allergies
  • Drug dosage errors


If we identify a problem during our review, we'll work with your doctor to correct the problem. For more detailed information about your Clover prescription drug coverage, please review your Evidence of Coverage and other plan materials.

 

Formulary-Level Opioid Point-of-Sale Safety Edits

To align with CMS Medicare Part D Opioid Overutilization Policy, we partnered with our pharmacy benefits manager, CVS Caremark, to develop safeguards that protect your safety and encourage appropriate prescription opioid use. These are not intended as prescribing limits.

7-day supply edit for opioid naïve patients*

 

  • Designed to identify members with no history of an opioid prescription in the past 108 days and decrease their initial supply to 7 days or less 

 

Update 90 mg/day MME (morphine milligram equivalent) soft reject (care coordination edit)*

 

 

  • Checks for excessive opioid utilization via cumulative 90 mg/day MME across multiple drugs and prescriptions 

 

Opioid/benzodiazepine POS (point-of-service) soft reject edit*

 

  • Designed to identify members receiving a medication from both classes of drugs

 

Duplicate long-acting opioid POS soft reject edit*

 

  • Designed to identify members on two or more long-acting opioids
Additional CVS Health opioid changes for standard Med D formularies*

 

  • Immediate release before extended release prior authorization 
  • Quantity limits for opioid-containing products based on limitations of up to 90 MME/day (when possible) and/or the FDA-approved maximum dose

*Patients in active cancer treatment, patients with sickle cell disease, Long Term Care (LTC) residents,
patients in hospice or palliative care and Buprenorphine for 
Medication Assisted Treatment (MAT) are exempt from these edits

We request that providers respond timely to pharmacy requests for additional information related to opioid safety alerts. Please ensure your on-call staff is aware and responds with a sense of urgency to pharmacy outreach. This will avoid delays in needed drug therapy.

If you have questions, please call the CVS Caremark Customer Care number on your Clover member ID card. For PPO plans, call 1-855-479-3657. For HMO plans, call 1-844-232-2316.

Medication Therapy Management

The Medication Therapy Management program works to identify members who are at risk for potential drug-related problems, helping them better understand the drugs they take.

Learn more >