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Utilization Management

How does utilization management work?

To ensure you receive quality health care in the most appropriate setting, physicians, nurses, and other staff in our Medical Management Department work with your primary care physician and other health care professionals to coordinate:

  • Prior-authorization - Certain services and prescription drugs require our prior authorization to ensure coverage. This means the physician ordering the treatment or service must contact us to request prior approval. Authorization for certain services requires them to be medically necessary and provided by participating providers.

  • Concurrent review and case management - Our medical directors and nurses actively follow members who are hospitalized to ensure appropriate levels of care and services. These professionals coordinate with your physician for continues care in alternate settings if appropriate -- transfers to other institutions, coordinating discharge from the hospital, continued skilled care, home health care, therapies, etc.

  • 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 utilization management tools to encourage appropriate and cost-effective use of Part D medications. A team of doctors and pharmacists developed these requirements and limits to help us provide quality coverage to our members. These tools include but are not limited to: prior authorization clinical edits 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 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 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 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_EL8540M | Accepted date: 10/01/2020
Last updated: 10/01/2020