Utilization Management

For certain prescription drugs, CCHP SelectCare (HMO) has additional requirements for coverage or for limits on coverage. These requirements and limits ensure that members use these drugs in the most effective way and to control drug costs. A team of doctors and pharmacists developed these requirements and limits.

Examples of utilization management tools are described below:

1. Prior Authorization
   CCHP SelectCare (HMO) requires you to get prior authorization for certain drugs. This means that physicians will need to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug.



2. Quantity Limits
   For certain drugs, CCHP SelectCare (HMO) limits the amount of the drug that we will cover per prescription or for a defined period of time.



3. Step Therapy
   In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.



4. Generic Substitution
   When there is a generic version of a brand-name drug available, network pharmacies will automatically give you the generic version, unless your doctor has told CCHP SelectCare (HMO) that you must take the brand-name drug and have obtained a prior authorization.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the Formulary. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren't able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination).