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Quality Assurance

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most cost effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Examples of utilization management tools are described below.

Prior Authorization: We require you to get prior authorization for certain drugs. This means that your physician or provider will need to assist you to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug.

Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription for for a defined period of time. For example, we will provide up to 60 pills in a 30 day period for Celebrex.

Generic Substitution: When there is a generic version of the brand-name drug available, our network pharmacies will automatically give you the brand-name drug. You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. See the section 'How do I request an exception to the formulary?' for more information.

Y0010_MK 13121 Approved 12-31-2012
Last updated 11-14-2012