Quality Assurance and Drug Management Programs


Utilization management

For certain prescription drugs, we've set in place some additional requirements or limits on coverage. These requirements and limits ensure our members use medications in the most effective way possible, and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits to help provide quality coverage to our members. Here are some examples of these utilization management tools:

Prior authorization

For certain drugs, we require you to get prior authorization. This means your physician needs our approval before you're able to fill these specific 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 the drug for. For example, we'll cover a maximum of 30 tablets of LIPITOR per prescription.

Step therapy

In some cases, we’ll require your doctor to prescribe a certain medication first—instead of another—to treat your condition. If the one we’ve required proves less effective, we’ll then cover the other drug to treat your condition.

Generic substitution

When both a generic and brand-name drug are available, our network pharmacies will automatically provide you with generics—unless otherwise advised by your doctor. You can find out if your needed medication is subject to this limitation requirement by checking the formulary. If it is, you can request us to make an exception to our coverage rules.

Drug utilization review

Through CVS Caremark, we conduct drug utilization reviews for all of our members, making sure they're getting safe and appropriate care. These reviews are especially important for members who have more than one doctor prescribing medications. We conduct drug utilization reviews each time you fill a prescription, and by reviewing your records on a regular basis. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because you're 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're taking
  • Drug allergies
  • Drug dosage errors

If we identify a medication problem during our drug utilization 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.

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.

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