Quality assurance (QA) and utilization management (UM) policies and procedures.


At Bright Health, we put members’ health and safety first. As part of our Medicare Part D plan, Bright Health offers QA and UM programs at no extra cost to Part D members. These programs are designed to ensure the safe and appropriate use of prescription medications covered under Medicare Part D. The programs help identify potential risks and opportunities to improve your medication therapy.

Quality assurance (QA)

In this program, every time a prescription is dispensed, it is reviewed for:

  • Age/gender-related contraindications
  • Over-utilization (e.g., early refill) and underutilization
  • Clinically significant drug-drug interactions
  • Incorrect drug dosage or duration of drug therapy
  • Therapeutic duplication
  • Inappropriate or incorrect drug therapy
  • Patient-specific drug contraindications
  • Abuse or misuse

This program also periodically review claims data.

Utilization management (UM)

This program consists of three parts, and is designed to encourage the safe, appropriate and cost-effective use of Medicare Part D prescription drugs.

Prior authorization (PA) A PA requirement means the member or their doctor must get approval before your medication is covered at your pharmacy.

Step therapy (ST) A ST requirement means you must first try one drug to treat a medical condition before another drug will be covered for that same condition.

Quantity limits (QL) A Quantity Limit requirement limits the amount of a drug that will be covered with prior approval.

Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Medicare Part D plan.

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Last Updated: Fri Nov 23 2018

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Bright Health plans are HMOs and PPOs with a Medicare contract. Our plans are issued through Bright Health Insurance Company or one of its affiliates. Enrollment in our plans depends on contract renewal.

This information is not a complete description of benefits. Call 844-667-5502 | TTY:711 for more information.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

You must continue to pay your Medicare Part B premium.

Every year, Medicare evaluates plans based on a 5-star rating system.

Medicare beneficiaries may also enroll in Bright Health Medicare Advantage plans through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov 

Bright Health Medicare Advantage plans are plans with a network of doctors, hospitals, pharmacies, and other providers. Out-of-network/noncontracted providers are under no obligation to treat Bright Health members, except in emergency situations.

Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.

Other providers are available in our network. Most network providers participate through our Care Partner.

Bright Advantage Special Care (HMO SNP) has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) through 2021 based on a review of Bright Advantage Special Care (HMO SNP) Model of Care.

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