Quality Assurance Policies and Procedures

PrimeTime Health Plan’s Quality Assurance Program has policies and procedures including medication therapy management and drug utilization programs to prevent over and under utilization of prescribed medications to ensure measurements for medication error, reduction of drug interactions and promote member safety.

Utilization Management maintains methods to ensure cost-effective drug utilization management. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of these utilization tools include:

• Prior Authorization: We require you to get prior authorization for certain drugs.
• Quality Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
• Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition.
• Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.