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:

Formulary-Level Opioid Point-of-Sale Safety Edits

Since January 1, 2019, Clover Health’s drug management program will implemented several pharmacy-based edits to assist in addressing safety concerns regarding opioid prescriptions. To align with CMS Medicare Part D Opioid Overutilization Policy, we partnered with our pharmacy benefits manager CVS/Caremark® and developed point-of-sale edits to advocate patient safety for our members and encourage appropriate prescription opioid use. The drug management program or point-of-sale edits are not intended as prescribing limits.

 Summary: 2019 Med D Opioid Management Requirements
7-day supply edit for opioid naïve patients*


  • Hard reject for initial opioid prescription (short and long acting) for acute pain exceeding 7 days 
  • 60-day minimum look back period; CVS/Caremark® implementing a 108-day look back 
  • Safety edit, not transition fill eligible 


Update 90 mg/day MME soft reject (Care Coordination Edit)*



  • Plans must implement cumulative 90 mg/day MME soft edit 


Opioid/benzodiazepine POS (Point of Service) soft reject edit*


  • Soft reject POS Safety edit for the concurrent use of opioids and benzodiazepines 


Duplicate long-acting opioid POS soft reject edit*


  • Soft reject POS Safety edit for duplicate therapy of 2 or more long-acting opioid medications
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
    • MME = Morphine Milligram Equivalent 

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

CVS Health Implementation Details: 7-Day Limit for Opioid Naive Patients 

CMS Mandate for 2019 for for opioid naïve patients: All Med-D plans are expected to have a hard reject for an initial opioid prescription for acute pain that exceeds 7 days; patients in active cancer treatment, patients with sickle cell disease, hospice, LTC, palliative care are excluded from this edit

Edit Overview

  • Hard reject for Opioid Naïve Patients filling over 7-day supply of opioid (safety edit, not transition fill eligible) 
  • Buprenorphine products for Medication Assisted Treatment for Opioid Use Disorder not subject to this edit 
  • Edit will reject with reject code 925 (Initial Fill Days Supply Exceeds Limits) and 569 (Provide Notice: Medicare Prescription Drug Coverage and Your Rights) upon initial rejection 
  • Once 7-day reject is resolved, all opioid formulary or UM rejects with Transition Fill (TF) logic will execute applicable Transition Fill logic 

Ensuring Access for Patients Excluded from Edit and Avoiding Unnecessary Disruption

  • Exception criteria will apply and allow member to bypass 7-day edit for members in: 
    • Active cancer treatment using oncology GPIs or cancer ICD 10 diagnosis codes 
    • Long Term Care using Patient Residence Codes 03 or 09 
    • Hospice using Member level indicator 
    • Palliative Care using ICD 10 code Z51.5 
    • Diagnosis of sickle cell disease or if member has a medication used to treat sickle cell disease in their prescription history
  • CVS Health Pharmacy Help Desk can override edit if exception cannot be determined based on prescription claim/member data; conversation will be documented 

CVS Health Implementation Details: Improving DUR (Drug Utilization Review) Controls in Part D

CMS Mandate for 2019: POS DUR Edits

  • Cumulative Morphine Milligram Equivalent (cMME) soft reject edit at 90 mg/day MME 
  • Soft reject for the concurrent use of an opioid and benzodiazepine and duplicate long-acting opioids 

Edit Overview

Current POS MME edit updated to meet new Opioid Coordination of Care Safety Edit Requirements: 

  • New result of service override codes allow pharmacist to override edit - if appropriate - after consultation with prescriber, or if the pharmacist has documented an appropriate exception for edit 
  • Will change reject code 88 to add new MME reject code 922 (Morphine Equivalent Dose Exceeds Limits) 
  • Members excluded from edit include: 
    • Hospice - using the member level indicator 
    • Long Term Care (LTC) - using appropriate Patient Residence Codes 03 (Skilled Nursing Facility) and 09 (Intermediate Care Facility/Individuals with Intellectual Disabilities) 
    • Active treatment for cancer related pain using oncology GPIs with 180 day look-back 
    • Members receiving buprenorphine for Medication Assisted Treatment (MAT) using MAT GPIs
    • Diagnosis of sickle cell disease or if member has a medication used to treat sickle cell disease in their prescription history

Two new soft reject POS Safety edits: 

  • Concurrent use of Opioids and Benzodiazepines edit (using current Drug-Drug Interaction edit functionality) 
  • Duplicate Long-Acting Opioids edit (using current duplicate therapy edit functionality) 
  • Patients in active cancer treatment, patients with sickle cell disease, Long Term Care (LTC) residents, patients in hospice or palliative care and Buprenorphine for 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® Help Desk number on your patient’s Clover Health member ID card. For PPO plans, call 1-855-479-3657. For HMO plans, call 1-844-232-2316.

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 rosuvastatin 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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