AmeriHealth 65^® Plus

Quality Assurance

Our prescription claims processor has pre-dispensing drug utilization review (DUR) edit checks, which are performed on an on-line, real-time basis at the mail and retail network pharmacies. All prescriptions are compared against previous prescriptions filled by the same pharmacy, by other participating retail network pharmacies, and by the mail service pharmacy. All drug interactions are detected on-line when each prescription is entered into the pharmacy's system. If an interaction is identified, the pharmacist will review the patient history and may contact the prescribing physician prior to filling the prescription.

Our prescription claim processor's pre-dispensing drug utilization review activities are an integral component of our overall commitment to safety and quality. Alerting the pharmacy to potential drug interactions and/or duplicate therapies, and discussing these potential problems with the prescribing physician(s), ensures that the correct amount of the appropriate drug is being delivered. Our claims processor's drug utilization review procedures allow the pharmacist to override the alert once the pharmacist has reviewed the data with the patient and/or physician and has determined that the prescription is safe to dispense.

The following edit checks are completed on-line, real-time as a prescription is being dispensed:

• Duplicate Drug Therapy
• Too-Early Refill
• Low-Dose/High-Dose Alert
• Incorrect Daily Dosage
• Excessive or Questionable Days' Supply
• Drug to Drug Interaction
• Drug Age/Gender Interaction
• Drug-Pregnancy Interaction

In addition, physicians can be notified of these interactions or other clinical issues on a retrospective basis. The targeted drug utilization review (DUR) can be implemented to identify members who may be receiving improper doses or combinations of products, who may potentially be abusing narcotics, and those who are receiving high doses of medication. An automated check of drug claims data is performed to identify potentially inappropriate prescriptions for individual members. If the computer program finds that, based on a member's current medications, a particular prescription may have violated the criteria for optimal drug use, an advisory letter is sent to the prescribing physician(s) for further review.

Utilization management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members.

Examples of utilization management tools are described below:

Prior Authorization: We require 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 do not get approval, we may not cover the drug.

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

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.

You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. See Exceptions and Appeals for more information.

Drug utilization review

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

• Possible medication errors.
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
• Drugs that are inappropriate because of your age or gender.
• Possible harmful interactions between drugs you are taking.
• Drug allergies.
• Drug dosage errors.

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Medication therapy management programs

We offer medication therapy management programs at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.

We offer a medication therapy management program(s) for members that meet specific criteria. We may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you do not need to pay anything extra to participate. If you are selected to join a medication therapy management program, we will send you information about the specific program, including information about how to get the program.

These programs may have limited eligibility criteria and are not considered a benefit. They are available for the following conditions:

• Members with at least two chronic diseases (asthma, diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD) -and-
• Members using at least two prescriptions per month -and-
• Members most likely incurring Part D drug costs of $4000/year