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Quality assurance and utilization management policies and procedures

Quality assurance and utilization management policies and procedures

At Bright Health, we put members’ health and safety first. As part of our Medicare Part D plan, Bright Health offers Quality Assurance (QA) and Utilization Management (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.