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Drug Quality and Assurance Programs

We have established measures and systems to conduct drug utilization reviews for all our members to make sure that they are getting safe and appropriate care. The programs include real-time and historic review of prescriptions claims to reduce medications errors and adverse drug interactions. These reviews are especially important for members who have more than one doctor who prescribes their medications, use more than one drug, or have more than one pharmacy.

CCA Health conducts drug utilization reviews when your pharmacy fills your prescription at the point-of-sale. The claim may be electronically reviewed for the following:

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.


Drug Utilization Management

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

We also have special programs to help members use their drugs safely. We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time you fill a prescription. These tools include‚ but are not limited to: prior authorization‚ clinical edits‚ quantity limits, and step therapy.

Age limits: Some drugs may require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.

Quantity limits: For certain drugs, we limit the amount of the drug we will cover per prescription or for a defined period of time.

Prior authorization: We require 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 coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

Step therapy: In some cases, we require 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Generic substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher copay and/or the difference in cost between the brand-name and generic medications.

You can find out if your drug is subject to any one of these tools by looking in our Drug Formulary.

Choice and Plus Drug Formulary (2022)

Download:

You can also review reference documents in our Covered Drugs page.


Medication Therapy Management

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by CCA Health at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit. This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.

To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

1. Have at least 3 of the following conditions or diseases:

  • Chronic heart failure (CHF)
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Respiratory disease–asthma
  • Respiratory disease–chronic obstructive pulmonary disease (COPD)

AND

2. Take at least 8 covered Part D medications

AND

3. Are likely to have medication costs of covered Part D medications greater than $4,376 per year

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:

  • Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, by phone or mail, and/or your doctor if we detect a potential problem.
  • Comprehensive medication review: at least once per year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided to you confidentially via telephone by pharmacies operated by SinfoníaRx. The CMR may also be provided in person at your provider’s office, pharmacy, or long-term care facility. If you or your caregiver are not able to participate in the CMR, this review may be completed directly with your provider. These services are provided on behalf of CCA Health. This review requires about 30 minutes of your time. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors. This summary includes:
    • Medication action plan (MAP): The action plan has steps you should take to help you get the best results from your medications.
    • Personal medication list (PML): The medication list will help you keep track of your medications and how to use them the right way.

To obtain a blank copy of the personal medication list (PML) that can help you and your healthcare providers keep track of the medications you are taking, click here.

If you take many medications for more than one chronic health condition, contact your drug plan to see if you’re eligible for MTM, or for more information, please contact customer service at 1-844-866-3735 (TTY: 1-800-367-8939). Hours are Monday through Friday, 7 am to 5 pm Pacific Time.

We’re here to support you

866-333-3530 (TTY 711)
8:00 am to 8:00 pm PT, Monday through Friday