Utilization Management

Prescription Drugs

The Peoples Health pharmacy department, in conjunction with the contracted pharmacy benefits manager, maintains management reports and systems to assist in preventing over-utilization and under-utilization of prescribed medications including but not limited to, the following:

  • Compliance monitoring to improve adherence/persistency with appropriate medication regimens
  • Monitoring procedures to discourage over-utilization through multiple prescribers or multiple pharmacies
  • Quantity versus time edits
  • Early refill edits

The pharmacy department maintains methods to ensure cost-effective drug utilization management. These may include but are not limited to the following:

  • Step therapy
  • Prior authorization
  • Tiered cost-sharing
  • Quantity limits

 Medical Services

 When making decisions about what health care services are covered under your plan, we follow Medicare guidelines:

  • Decision-making is based only on appropriateness of care and services and existence of coverage
  • We do not reward practitioners or others for denying coverage
  • Financial incentives for decision makers do not encourage decisions that result in underutilization of services