Drug Management Programs

IU Health Plans’ (HMO) (HMOPOS) has several programs in place to make sure that members have access to their prescriptions in a way that is both safe and at the lowest cost.

Please view a topic below for more information about each program.

Utilization Management

For certain prescription drugs, IU Health Plans (HMO) (HMOPOS) has additional requirements for coverage or for limits on coverage. These requirements and limits ensure that members use these drugs in the most effective way and to control drug costs. A team of doctors and pharmacists developed these requirements and limits.

Examples of utilization management tools are described below:

Prior Authorization

IU Health Plans (HMO) (HMOPOS) requires you to get prior authorization for certain drugs. This means that physicians and other prescribers will need to get approval from us before the member fills their prescription. If they don't get approval, we may not cover the drug.

Quantity Limits

For certain drugs, IU Health Plans (HMO) (HMOPOS) limits the amount of the drug that we will cover per prescription or for a defined period of time.

Step Therapy

In some cases we require the member to first try one drug to treat the member?s medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, we may require you to prescribe Drug A first. If Drug A does not work for the member then we will cover Drug B.

Generic Substitution

When there is a generic version of a brand-name drug available, network pharmacies will automatically dispense the generic version, unless physician or other prescriber has told IU Health Plans (HMO) (HMOPOS) that the member must take the brand-name drug and you have obtained a prior authorization.

You can find out if the drug the member takes is subject to these additional requirements or limits by looking in the Formulary. If your drug is subject to one of these additional restrictions or limits and your physician or other prescriber determines that the member is not able to meet the additional restriction or limit for medical necessity reasons, you or your physician and other prescriber may request an exception (which is a type of coverage determination).

Drug Utilization Review

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time the member fills a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because the member is taking another drug to treat the same medical condition
  • Drugs that are inappropriate because of the member?s age or gender
  • Possible harmful interactions between drugs the member is taking
  • Drug allergies
  • Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with you to correct the problem.

Medication Therapy Management (MTM) Programs

IU Health Plans (HMO) (HMOPOS) has partnered with PerformRx to offer medication therapy management programs at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. A team of pharmacists and doctors developed these medication therapy programs to help provide better prescription drug coverage for plan members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help IU Health Plans (HMO) (HMOPOS) identify possible medication errors.

IU Health Plans (HMO) (HMOPOS) offers medication therapy management programs for members who meet specific criteria. As a IU Health Plans (HMO) (HMOPOS) member your patient may be notified of enrollment into the program. IU Health Plans (HMO) (HMOPOS) hopes that they will participate in the program offered to help manage their medications. Remember, members do not need to pay anything extra to participate. If selected as an eligible participant for a medication therapy management program, IU Health Plans (HMO) (HMOPOS) will send the member information about the specific program, including information on how to disenroll should they choose not to participate.

Click here for the 2012 Eligibility Criteria
Click here for the 2013 Eligibility Criteria

For more information, contact Member Services at 866.907.1587 (TTY 800.743.3333) 8:00 a.m. to 8:00 p.m., seven days a week.

MODIFY DATE: 03/24/2014 3:17:06 PM PMMODIFIED BY: jnaffzig@iuhealth.org