Northeast Community Care has established quality assurance measures and systems to reduce medication errors and adverse drug interactions and improve medication use. Following is more information about our programs.

General Information

• Drug Utilization Management Programs
• Medication Therapy Management Program
• Transition Plan

Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:

• Prior Authorization: We require you to get prior authorization for certain drugs. This means that network providers will need to get approval from us before you fill your prescription. If you don't get approval, we may not cover the drug.
• Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will only provide up to 90 capsules per 365 days for Nexium.
• Step Therapy: In some cases, we will require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Lisinopril and Diovan both treat your blood pressure, we may not cover Diovan unless Lisinopril was tried and did not work for you.
• Generic Substitution: If an FDA-approved generic version of a brand name drug is available, network pharmacies will automatically provide you with the generic medication, unless your physician has specified "do not substitute" on the prescription.
• Part B vs. Part D Determination: Many drugs can be covered under the Part B medical benefit, but most are also covered under the Part D pharmacy benefit. The Pharmacy Department must make the determination on this coverage based on rules and guidelines regarding Part B vs. Part D set forth by Medicare. Generally, medications that are considered self-injectable, such as Procrit, are available for coverage under the pharmacy benefit. Most injectable products require pre-authorization for coverage

Drug Utilization Review

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

• Possible medication errors.
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
• Drugs that are inappropriate because of your age or gender.
• Possible harmful interactions between drugs you are taking.
• Drug allergies.
• Drug dosage errors.

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

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The Medication Therapy Management Program (MTMP) is available to certain Medicare beneficiaries to help improve medication use and reduce the possibility of adverse drug reactions and to optimize your medical outcomes using your prescription drugs. This program has limited eligibility criteria as listed below.

Criteria to participate include:

• Three or more of the following chronic conditions: hypertension, diabetes, congestive heart failure (CHF), or dyslipidemia.
  
  AND
• Taking a total of nine (9) or more covered Part D medications used to treat one or more of the conditions listed in #1.
  
  AND
• Yearly drug expenditures (total drug costs) expected to be at least $3,000.

This program is not a benefit, but is available to all beneficiaries who may qualify. If you think you qualify for this program, please contact us and we will determine your eligibility. Once enrolled in the program, you will be contacted by a pharmacist to discuss your medications with you and consult with your doctor if necessary. Alternative therapies will be suggested to maximize your therapy and hopefully decrease your out-of-pocket costs. Disease management materials will be provided to you if available. The goal of the program is to provide drug quality improvements.

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As new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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