What is Quality Assurance?

This is a sign of our dedication to providing quality healthcare. 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 that are not appropriate for your age or gender

Retrospective Drug Utilization Review

This occurs after a prescription is filled. This process reviews members' drug histories 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 overuse and underuse of prescribed medications.

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

Prior Authorizations & Exceptions

We require you to get prior authorization for certain drugs on formulary. This means you will need to get approval from our Pharmacy Benefit Administrator (PBA), Capital Rx, before you fill prescriptions for these drugs. If you do not get approval, Baylor Scott & White Health Plan may not cover the drug. Additionally, to request coverage for a drug not listed on formulary, an exception request must be submitted to the PBA.

Quantity Limits

For certain drugs, there are limits to the amount of the drug that we will cover. For example, we provide up to a certain number of tablets per prescription for a certain 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, Baylor Scott & White Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Baylor Scott & White Health Plan will then cover Drug B.

Use of Generic Drugs

We cover 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).

As a new or continuing member, you might be taking drugs that are not on our formulary or taking a drug that requires you to meet certain requirements, like preauthorization, step therapy or quantity limits.

If you're in the first 90 days of coverage for this plan year, we'll cover a temporary 30-day supply of your drug at any in-network pharmacy to give you time for you and your doctor to plan your future treatment. If you're at a long-term care facility, we will cover a temporary 31-day supply of your drug at any in-network pharmacy.

Talk to your doctor about whether you should switch to a drug on our formulary or request an exception to see if we can cover the drug you're taking. You can view our full Medicare Part D Transition Policy to learn more. If you need assistance requesting an exception or have questions about the transition process, contact us.