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Clinical Programs

With so many medications available today – and more and more people taking them – managing use, costs, and safety can be complex. Our comprehensive, effective clinical programs are a critical component of our prescription drug benefits, where the goal is to improve compliance, savings and safety.

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Notification/Prior Authorization The notification program promotes safety and reduces overall health care costs. With this program, doctors are required to provide additional clinical information to verify benefit coverage.
Step Therapy Most therapeutic classes of drugs have multiple medication options – and many of those are interchangeable. Although their clinical effectiveness is similar, the prices may vary widely. Step Therapy directs members to less expensive, but equally effective medications when they are available – before coverage is provided for a more costly alternative.
Supply Limits Our supply limits program addresses safety, reduces waste and removes excess costs by establishing a maximum quantity of medication that can be dispensed per payment or in a specified timeframe.
High Narcotic Utilization Although most members use prescription narcotics appropriately, opiate abuse has received increased attention. Our High Narcotic Utilization program reviews pharmacy claims information quarterly to identify members who may be inappropriately seeking narcotic prescriptions from several providers. Those identified are tracked on an ongoing basis and pharmacy limitations may be implemented.

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