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Utilization Management

How utilization management works for you

Utilization management (UM) is a process that is part of your health plan. Utilization management helps to make sure that you are getting the right drugs -- all while helping to make medicine more affordable.

Utilization management is made up of several different programs

Health plans call for utilization management on some medicines to keep you safe, by helping to make sure the medicines you take are prescribed by your doctor and used correctly. Utilization management is made up of programs that include:

  • Step therapy helps lower costs through safe, less expensive drugs. This program uses a "step" approach with drugs for certain conditions. This means that you may have to first try a safe, lower-cost drug, or one that may be more clinically effective, before "stepping up" to a different drug.
  • Prior authorization helps improve safety. Some drugs can be misused or overused, or may not be the best choice for your health condition. Prior authorization (sometimes called pre-approval) means that your medicine needs to be approved by your health plan before it will be covered.
  • Quantity limits helps to lower waste. This program controls how often or the amount you can get filled at once. These limits promote safe, cost-effective drug use. They also help reduce waste and overuse.

What to do when your prescription needs utilization management

When you or your doctor sends a prescription to the pharmacy, the pharmacist will enter it into the system. If the drug you have been prescribed has a UM program attached to it, the pharmacist will get an alert about the program type and will let you know the next steps.

  • See if your plan covers a different medicine to treat your condition. Contact us to find out if we cover another drug that is used to treat your condition, or log into MyPrime.com to look up the medicine on your drug list. If a similar drug is covered, ask your doctor if it might be a good choice for you.

  • Find your forms. MyPrime.com has the forms you'll need if one of your prescriptions needs utilization management.
  • Your doctor may ask for an exception. If your doctor feels that the original medicine is best for you, he or she can submit a request for an exception. Most exception requests are reviewed within 48 hours. We can work with your doctor to help make sure you’re getting the right medicine for you.

The first step to getting an exception is to ask your prescribing doctor to call the number on the back of your member ID card.

Your doctor must submit a statement supporting your request. The doctor's statement must explain how:

  • This drug is medically necessary to treat your condition
  • None of the drugs that are covered by your plan would be as effective, or they would have unwanted effects.

Utilization management programs are important

Health plan companies, hospitals, doctors and pharmacists share information — working together to help improve medicine for members. UM programs help to catch mistakes, reduce waste, improve safety and keep medicine affordable by lowering costs.

If you have any questions, we’re here to help. Contact us 24/7.