Utilization Management
Prescription Drugs
The Peoples Health pharmacy department, with the contracted pharmacy benefits manager, maintains management reports and systems to assist in preventing over-utilization and under-utilization of prescribed medications including but not limited to, the following:
- Compliance monitoring to improve adherence/persistence with appropriate medication regimens
- Monitoring procedures to discourage over-utilization through multiple prescribers or multiple pharmacies
- Quantity versus time edits
- Early refill edits
The pharmacy department maintains methods to ensure cost-effective drug utilization management. These may include but are not limited to the following:
- Step therapy
- Prior authorization
- Tiered cost-sharing
- Quantity limits
Medical Services
When making decisions about what health care services are covered under your plan, we follow Medicare guidelines:
- Decision-making is based only on appropriateness of care and services and existence of coverage
- We do not reward practitioners or others for denying coverage
- Financial incentives for decision makers do not encourage decisions that result in underutilization of services