Quality assurance (QA) and utilization management (UM) policies and procedures.
At Bright HealthCare, we put members’ health and safety first. As part of our Medicare Part D plan, Bright HealthCare offers QA and UM programs at no extra cost to Part D members. These programs are designed to ensure the safe and appropriate use of prescription medications covered under Medicare Part D. The programs help identify potential risks and opportunities to improve your medication therapy.
Quality assurance (QA)
In this program, every time a prescription is dispensed, it is reviewed for:
Dosing: We check how much of each drug you take to find out if it is within established dosage ranges, meaning not too high or too low.
Gender/Age: We screen a prescribed drug to find out if it is right for a member’s gender and age.
Proper Medication Use: We look at the time frame for refills and new fills. We do this to make sure that members take their prescribed drugs as directed and follow established dosing guidelines for controlled and non-controlled substances.
Drug-Drug and Drug-Disease Interaction: We look at medication profiles to find any potential interactions between prescribed drugs and a member’s health conditions.
Medication Duplication: We screen each member profile to make sure that newly prescribed drugs are not the same as other prescribed drugs the member is taking.
FDA–issued Warnings: We review FDA-issued warnings about any harmful reactions to medications, new dosage formulations and how the drug is administered (orally, injectable, topically, etc). We re-evaluate the formulary (list of covered drugs) to make improvements based on our reviews.
This program also periodically reviews claims data.
Utilization management (UM)
This program consists of three parts, and is designed to encourage the safe, appropriate and cost-effective use of Medicare Part D prescription drugs.
Prior authorization (PA): Bright HealthCare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Bright HealthCare before you fill your prescriptions. If you don’t get approval, Bright HealthCare may not cover the drug.
Step therapy (ST): In some cases, Bright HealthCare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Bright HealthCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Bright HealthCare will then cover Drug B.
Quantity limits (QL): For certain drugs, Bright HealthCare limits the amount of medication. For example, Bright HealthCare provides 30 tablets of atorvastatin per month which equals 1 tablet per day. If you need more than the limit listed, your provider can submit an exception for you to get more.
Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Medicare Part D plan.
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Website Last Updated: Nov 21 2021