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Some drugs need to be approved by the plan before they are covered. This is so the plan can best guide the correct use of these drugs. Your doctor can help you get approval.
The plan can ask you to start treatment with a drug that costs less but works just as well (for example, a generic name drug) instead of starting with a drug that costs more. If the first drug doesn’t work for you, then the plan will cover the higher-priced drug.
There can be limits on how much of a drug you’re allowed. The limit could be for how many pills you get with each prescription. These limits are based on safety guidelines.
Drug utilization reviews help make sure you’re getting safe and proper care. They are very important if you have more than one doctor prescribing your medications. The review is done each time you fill a prescription, as well as on a regular basis. We look for issues such as:
If we find a problem during the review, we’ll work with your doctor to fix it.