Utilization Management

How do we promote medication safety?

You get more than health coverage from us. When it comes to prescription drugs, you get a team of doctors and pharmacists looking out for your safety—and your budget. These experts help us develop programs we use to:

• Identify potential problems with your prescription.
• Make sure you’re getting the right drug for the right situation.
• Lower prescription drug costs.

Here’s how they work.

Utilization management

That’s what we call managing the use of certain prescription drugs. We do this by adding requirements that need to be met before your plan covers these drugs. Or there may be limits on how many times you can fill a prescription. There programs include:

• Step therapy
• Prior authorization
• Quantity limits (for example, we may only approve a 31-day supply of some drugs)
• Authorizing our network pharmacies to substitute a generic drug for a brand-name drug where permitted

You can find out if the drug you take has any of these restrictions by looking in your plan’s drug formulary, which can be found here. You can also call the Customer Service number on the back of your WyoBlue Advantage ID card.

If because of medical necessity your can’t meet a restriction, you or your doctor can request an exception by filling out the coverage determination form.

Drug utilization review

Every time you fill a prescription, we review your records to make sure your prescriptions are safe and appropriate. We do this for all our members on a regular basis. These reviews are especially important if more than one doctor prescribes medications for you. We look for problems like:

• Possible medication errors
• Drugs that are unnecessary because you’re taking another drug to treat the same medical condition
• Drugs that aren’t right for you because of your age or gender
• Possible harmful interactions between drugs you’re taking
• Dug allergies
• Errors in the dosage for a drug you’re taking

If we see a problem, we’ll work with your doctor to correct it.