We conduct drug utilization reviews to help ensure members are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor prescribing their medications.
We review member drug utilization each time members fill a prescription and also by regularly reviewing our records.
We look for medication problems such as:
If we identify any problems, we share our findings with you and discuss other alternatives. You may receive calls or faxes from our pharmacy department following up on findings. If you have questions, please contact the pharmacy department.
We delegate prior authorization services to OptumRx®. OptumRx staff adhere to benefit plan-approved criteria, National Pharmacy and Therapeutics Committee (NPTC) practice guidelines, and other professionally recognized standards.
We offer a formulary exception process to allow for cases where the formulary or its restrictions may not accommodate the unique medical needs of members. To request an exception, submit a prior authorization request as described below. If you request an exception, you must also submit a supporting statement explaining why the exception is being requested.
Generally, we will only approve your request for an exception if alternative drugs included on our formulary list, a lower-tiered drug, or additional utilization restrictions would not be as effective in treating the member’s condition or would cause the member to have adverse medical effects.
New members taking drugs that are not on our formulary list, or for which there are restrictions, should talk with you to decide if they should switch to another appropriate drug that we do cover, or if you should request an exception.
You can request an authorization or exception by:
This online service enables physicians and health care professionals to submit a real-time prior authorization request 24 hours a day, seven days a week. After logging on at OptumRx.com with their unique National Provider Identifier (NPI) number and password, a physician or health care professional can submit patient details securely online, enter a diagnosis and medical justification for the requested medication, and, in many cases, receive authorization instantly.
Our network pharmacies may recommend or give members the generic version of a drug unless you tell us otherwise. Brand name drugs may require our approval if the generic equivalent is covered.
The pharmacy may contact you by phone, letter, or fax to request that a member be switched to a preferred alternative drug.