Texas Rx Quality Assurance Policies

What is quality assurance?
What is drug utilization management?
What is Medication Therapy Management (MTM) Program?

What is quality assurance?

Scott & White Health Plan is dedicated to providing quality health care. Quality assurance includes measures and systems to reduce medication errors and adverse drug interactions and improve medication use.

Examples of quality assurance processes in relation to Medicare Part D may include the following:

Concurrent Drug Utilization Review - This occurs when a prescription is being filled at the pharmacy. Your prescriptions are reviewed for safety issues that may address the following:

Possible medication errors
Drug dosage and therapy duration errors
Duplicate drugs that are unnecessary because you are taking another to treat the same medical condition
Drug allergies
Possible harmful interactions between the drugs you are taking
Drugs which are not appropriate for your age or gender

Retrospective Drug Utilization Review - This occurs after a prescription is filled. This process reviews members' drug history and identifies opportunities to improve the quality of care by identifying patterns of inappropriate or medically unnecessary therapy.

What is drug utilization management?

Drug utilization management programs are designed to improve quality and reduce costs when medically appropriate. The program includes systems to assist in preventing over-use and under-use of prescribed medications.

Examples of utilization management in relation to Medicare Part D may include the following:

Prior Authorizations: Scott & White Health Plan requires you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for the coverage though our exceptions process). This means that you will need to get approval from Scott & White Health Plan before you fill your prescriptions. If you do not get approval, Scott & White Health Plan may not cover the drug.

Quantity Limits: For certain drugs, there are limits to the amount of the drug that Scott & White Health Plan will cover. For example, Scott & White Health Plan provides up to a certain number of tablets per prescription for a certain drug.

Step Therapy: In some cases, Scott & White Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Scott & White Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Scott & White Health Plan will then cover Drug B.

Use of Generic Drugs: Scott & White Health Plan covers both name brand and generic drugs. A generic drug has the same active ingredient as the name brand drug. Generic drugs usually cost less than name brand drugs and are approved by the Food and Drug Administration (FDA).

What is Medication Therapy Management (MTM) Program?

It is a new program, required by Medicare Part D, to help ensure the appropriate use of prescription drugs to improve your health and reduce adverse events from medications.

It is a voluntary "medication check-up and wellness" program provided by a Scott & White Health Plan pharmacist and offered to certain people that are enrolled in a Medicare Part D prescription drug plan.

Who is eligible?
Any person enrolled in the Scott & White Health Plan Texas Rx plans is eligible for the MTM Program. However, Medicare does indicate that in order to be eligible for MTM services, a member must meet specific criteria.

In order to be eligible for the MTM program offered by Scott & White Health Plan Texas Rx plans, a member must meet ALL of the following criteria:

Have at least two chronic disease states, which may include, but are not limited to diabetes, hypertension, dyslipidemia, asthma, or congestive heart failure.
Take at least two chronic medications that are covered by Texas Rx (any two formulary medications that are taken or will take for three months or longer).
Spend greater than or equal to $4,000 a year on drugs.

What types of MTM services are offered?
Different types and levels of MTM services will be offered, at minimum, once or twice a year. Services may include, but are not limited to the following: a Comprehensive Medication Therapy Review, a Personal Medication Record, and a Medication/Health Action Plan.

How do patients enroll?
Once you are identified as eligible, you will receive information in the mail encouraging you to participate and information on how to enroll in the MTM program.

Is there a fee for MTM services?
There is no additional cost to you for MTM services as long as you meet the above specified criteria.