Pharmaceutical Management

General Overview

Pharmaceutical Management (Clinical Management Programs) is designed to safeguard patients from potentially harmful drug interactions and side effects, optimize clinically appropriate therapy, promote appropriate prescription drug utilization and promote compliance with recommended drug quantity, dosage and intended use of product. These programs bring together every individual or entity involved in the management and delivery of pharmaceutical care: plan sponsor, physicians, members, and pharmacists. The programs are administered across all lines of business and are seamless across both retail and home delivery prescription drug benefit programs. These programs achieve their goals by:

• Identifying specific prescribing situations that may represent inappropriate utilization based on nationally-recognized clinical practice guidelines or manufacturer's recommended dosages.

• Providing the appropriate clinical interventions and follow up necessary with physicians and patients to foster more appropriate and effective use of prescription therapy.

Pharmaceutical Management Programs

Pharmaceutical management programs include the following:

• Quantity Level Limit Policy - To view policies, view Pharmacy Policy Search - always available on the left menu, as well as at the top of this page in the Quicklinks bar.
• Prior Authorization
• Process for Requesting Drug Coverage from a Pharmaceutical Management Program

Changes and updates to all clinical management programs are distributed bi-monthly through the Formulary Update, which is distributed to all network providers.