Utilization Management

Healthcare is often about finding the right balance — and that’s definitely true with prescription drugs. The right medication in the right dose can save your life. But get it wrong, and it can be very harmful.

Utilization management is a set of rules, programs, and safety checks with two goals in mind. First, we want to make sure you take medications that are safe for you — and that you take them in the most effective way. Second, we want to keep your drug costs down. 

We worked with doctors and pharmacists to create our utilization management tools — you can read about them below. Learn more about how to request an exception or file a complaint here. As always, if you have any questions, call us at 1-800-DEVOTED (1-800-338-6833), TTY 711.

Prior Authorization (PA)

Before you get some drugs, you need prior authorization (PA). That means your provider has to check with us first to make sure we’ll cover them. This is one way we use to make sure you’re getting the right drug for you.

Quantity Limits (QL)

For certain drugs, you’re covered for only a limited amount of medicine — or for a set length of time. These are called quantity limits. For example, you might only be covered for 30 pills in one month. We use this for safety reasons and to control costs.

Step Therapy (ST)

Before you can get certain medications, you’ll first need to try one that costs less and has been proven to work for your condition. If the lower cost drug doesn’t help you, then you can step up to the more expensive one. 

Generics Before Brand Names

When a drug comes as both a generic and a brand name, our pharmacies will usually give you the generic one — unless your doctor says you need the brand name. This is another way to keep drug costs in check. (Note: In rare cases where the generic is higher-cost, we may cover the brand name instead.)

Drug Utilization Review 

With CVS Caremark, our pharmacy partner, we do drug safety checks known as utilization reviews. Each time you fill a prescription — and sometimes in between — we check that:

• You get the right medication and dose
• You aren’t already taking a drug that treats the same condition
• You don’t have a known allergy to the drug
• The drug is safe for someone of your age and sex
• The drug is safe to take with your other medications

If we find a problem, we work with your doctor to correct it. 

Medication Therapy Management

When you have to take a number of drugs, it can be a challenge to keep it all straight. And safety becomes even more important. Medication Therapy Management is a program that can help. Learn more here.