How does utilization management work?
To ensure you receive quality healthcare, we work with your Primary Care provider and other healthcare professionals to coordinate:
-
Prior-authorization - Certain services and prescription drugs need a prior authorization before they are covered. Your provider will contact us and we'll work to make sure you have the care you need.
-
Concurrent review and case management - If you have been hospitalized, we work with you to ensure you receive the level of care you need. We'll coordinate care in a different location if needed. That might include another hospital, discharge, skilled nursing care, or home health.
-
Retrospective review - Medical Management professionals also review certain services after they are delivered to determine if they were medically necessary and appropriate.
Part D Prescription Drug Information
This program incorporates tools to ensure the appropriate and cost-effective use of Part D medications. A team of doctors and pharmacists develop requirements and limits to help provide quality coverage to all our members. Some of these tools include prior authorizations, quantity limits, and step therapy.
- Age Limits: Some drugs may require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations
- Quantity Limits: For certain drugs, we limit the amount of the drug we will cover per prescription or for a defined period of time
- Prior Authorization: We require you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or for drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don't get approval, Health First Health Plans may not cover the drug
- Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B
- Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher copay and/or the difference in cost between the brand and generic medications
You can find out if your drug is subject to any one of these tools by looking in the Health First Health Plans Formulary available below:
Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.
Y0089_EL108008_M | Accepted date: 10/01/2023
Last updated: 10/01/2023