Quality Assurance policy and procedure

Providence Medicare Advantage Plans is committed to keeping you safe and healthy. Providence has implemented programs to ensure safe and appropriate use of prescription drugs that are part of your Medicare Part D benefit. These programs will bring any potential risks or questions to your pharmacist’s attention and help your provider and pharmacist talk about your medicine, if needed. 

Medication Quality Assurance Program

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We automatically check your prescriptions each time you fill one. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Drugs that may not be necessary because you are taking another drug to treat the same health condition
• Drugs that may not be safe or appropriate because of your age or gender
• Certain combinations of drugs that could harm you if taken at the same time
• Prescriptions written for drugs that have ingredients you are allergic to
• Possible errors in the amount (dosage) of a drug you are taking
• Unsafe amounts of opioid pain medications

If we see a possible problem in your use of medicines, we will work with your provider to correct the problem.

Why do some drugs have restrictions or limits?

Medicare has special rules that limit how and when the plan covers some medicines. Your health plan must follow these rules. A team of doctors and pharmacists developed these rules to help members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. 

In general, the rules encourage you to get a drug that is safe to use and works well to treat your condition. Whenever a safe, lower-cost drug will work just as well as a higher cost drug, the plan’s rules ask you and your provider to use that lower-cost option first.

If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to see if we can cover the drug. For example, if you want the restriction waived, you or your provider will need to use the coverage decision process to ask us to make an exception. We may or may not agree to waive the restriction for you. (See  Chapter 9, Section 6.2 for information about asking for exceptions.) 

Please note that sometimes a drug may appear more than once in our drug list. This is because different restrictions or cost sharing may apply based on factors such as the strength, amount, or form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one per day versus two per day; tablet versus liquid).

• Limiting brand name drugs when a generic version is available
  A generic drug works the same as a brand name drug and usually costs less. When a generic version of a brand name drug is available, our network pharmacies may provide you the generic version. We usually will not cover the brand name drug when a generic version is available, unless the brand is on the formulary. However, if your provider has told us the medical reason why neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)
• Getting plan approval in advance
  For certain drugs, you or your provider need to get approval from the plan before the drug is covered. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
• Trying a different drug first
  This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called “step therapy” or may be required if your requested drug is not on your covered list of drugs. 
• Quantity limits
  For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.