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 the member to first try one drug to treat their medical condition before we will cover another drug for that condition.  For example, if Drug A and Drug B both treat the medical condition, we may require you to prescribe Drug A first.  If Drug A does not work for the member 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 dispense the generic version, unless you have told CCHP SelectCare (HMO) that the member must take the brand-name drug and you have obtained a prior authorization.

You can find out if the drug you are prescribing is subject to these additional requirements or limits by looking in the Formulary. If the drug is subject to one of these additional restrictions or limits and you determine that the member is not able to meet the additional restriction or limit for medical necessity reasons, you may request an exception (which is a type of coverage determination).

• Click here for more information about Coverage Determinations, Exceptions & Appeals.