Quality Assurance and Drug Management Programs
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
Beginning January 1, 2019, Clover Health’s drug management program will implement 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.
|7-day supply edit for opioid naïve patients||
|Update 90 mg/day MME soft reject (Care Coordination Edit)||
Opioid/benzodiazepine POS (Point of Service) soft
Duplicate long-acting opioid POS soft reject edit
|Additional CVS Health opioid changes for standard Med D formularies||
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, hospice, LTC, palliative care are excluded from this edit
- 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 - new reject code for 2019) 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
- 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
- Plans may have an optional hard reject at a cMME of ≥ 200 mg/dayMME
- Soft reject for the concurrent use of an opioid and benzodiazepine and duplicate long-acting opioids
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)
- Optional hard reject at >200 mg/day MME will include G4 (Prescriber Must Contact Plan) with the 922
- 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
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)
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.
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.
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.
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.
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.