PHARMACY UTILIZATION MANAGEMENT - PRIOR AUTHORIZATIONS

Effective Date: 
Wed, 05/27/2020
Policy: 

UC SHIP benefit plan includes a formulary of allowed medications for prescriptions.  In an effort to reduce expenses and to follow all safety guidelines, UC SHIP has a Utilization Management Plan within that formulary.  This formulary is updated twice annually in January and July.

Establishing guidelines for use
The benefit plan has a review committee of doctors and pharmacists meets often to review medications and consider coverage under pharmacy UC SHIP. They also recommend quantity limit guidelines, exclusions, step therapy and prior authorizations.

UC SHIP’s QUANTITY LIMITS program protects patients and can help patients get the best results from medication therapy. Along with safe and appropriate doses, QUANTITY LIMITS can also keep prescription drug costs lower.

Determining quantity limits
Quantity limits are meant to lower the risk of overuse. Quantity limit rules are based on:
• Food and Drug Administration (FDA) approved uses
• Medication instruction labels
• Accepted or published clinical recommendations

PRIOR AUTHORIZATIONS are required for medication coverage because they’re only approved or effective in treating specific conditions. See the Process in the Procedure.

STEP THERAPY requires that less expensive and/or safer products be used first, before selecting newer or special products.  A PRIOR AUTHORIZATION may be needed for the newer/special product.

Procedure: 

PRIOR AUTHORIZATION PROCESS

1. Check the EMR for the formulary in Orders > Medication Orders

2. Check the EMR References for Utilization Management

3. go to the login for PreCheckMyScript (PCMS) at https://provider.linkhealth.com/#/ 

4. Enter the patient information including the Anthem Insurance Number.  Note: Use just the number, unless the number is preceded by CA.  If so then include CA.

5. Agree to the requirements

6. Enter the medication and select the formulation

7. Answer the associated questions and enter any supporting documentation if required

8. Wait for the response

9. Cut and Paste the response in the EMR in the patients medical record

10. Alert the Pharmacy with an IM or Secure Message for that encounter note, if the student will receive the medication from the UCSC Pharmacy

11. Set a "Reminder" in the EMR for the date it will expire and will need to be re-authorized

12. When the response is loaded into the EMR, acknowledge the document 

 

For any problems, call 800-626-0072

 

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