Quality assurance policies and procedures

• What is quality assurance?
• Quality assurance programs
• Utilization management
• Medication therapy management program

What is quality assurance?

Quality assurance includes the processes and systems put in place to evaluate prescriptions for health and safety issues. They help promote the appropriate use of medications by improving compliance and reducing medication errors and adverse drug interactions.

Quality assurance programs

BCBSNC’s quality assurance processes are summarized below:

• Concurrent drug utilization review (DUR) - This occurs while a claim is being processed at the pharmacy. Prescriptions are screened for the following safety issues and the pharmacist is sent a message immediately, alerting them of the potential issue.
  
  
  • Drug interactions - Instances when the prescribed drug can potentially result in ineffective or unsafe treatment when used in combination with another drug.
    
    
  • Drug-allergy - Identifies when the prescribed drug may potentially cause problems based on patient’s reported allergies.
    
    
  • Drug-disease - Instances when the prescribed drug may potentially worsen the patient’s reported medical condition(s).
    
    
  • Drug-gender contraindications - Identifies prescription medications being inappropriately filled based on patient gender.
    
    
  • Drug-age - Identifies those drugs that are contraindicated for use by older adults.
    
    
  • Excessive daily dosing and duration of therapy - Identifies when a prescription claim is being filled for more than the recommended maximum daily dose or duration.
    
    
  • Refill too soon or too late - Identifies patients who may not be taking their medication as prescribed by their physician.
    
    
  • Therapy duplication - Identifies when the prescription being filled is from the same therapeutic class as other medications in the members profile.
    
    
  • Potential drug name confusion - Identifies prescriptions that sound alike, or when written, look alike.
  
  
• Retrospective drug utilization review (DUR) - This occurs after the prescription has been dispensed. It is a program that evaluates a members’ drug history to identify prescribing issues. Alerts are provided by mail to physicians, addressing prescribing practices and uses that are unsafe, ineffective, or otherwise inconsistent with evidence-based standards of care. Retrospective DUR complements the concurrent DUR program by identifying physicians who for some reason may be resistant to the messages generated by concurrent monitoring.
  
  

  The retrospective DUR health and safety alerts are made up of four key categories:

  • Potential drug-drug interactions - Instances when prescribed medications can potentially result in ineffective or unsafe treatment when used in combination with another drug
    
    
  • Dose considerations with pain medications - Examines the use of certain high dose pain medications
    
    
  • Drug age considerations - Considers the adverse effects of certain drugs or drug classes on the elderly population.
    
    
  • Therapy duplication - Identifies the use of two or more drugs in the same therapeutic class that may put the patient at risk of additional unwanted side effects or adverse medical event.
  
  
• Refill reminders to patients - As part of the dispensing process, a refill notice is generated by computer and included with each dispensed mail-order prescription. The e-mail refill reminder program is designed to remind plan members to refill and continue to take important medications, specifically those medications that are for chronic conditions for which there may not always be signs and symptoms of illness.

Utilization management - prior authorization, quantity limitations, and generic drug substitution    

What is prior authorization and quantity limitations?

• Prior authorization is a program that requires members to meet certain clinical criteria prior to a drug being covered.
  
  
• Quantity limitations define the amount of medication that will be covered for each copayment or over a defined period of time. To receive a quantity of medication that exceeds the quantity limit, the member must meet certain criteria.

Prior authorization and quantity limits encourage the appropriate use and dose of prescribed medication based on the U.S. Food and Drug Administration (FDA) approved labeling and other medical literature.

Members have the right to request an exception to the formulary or to request a transition supply. To learn how to request prior authorization or an exception to a quantity limit, review our prior authorization, nonformulary request and quantity limits section.

For questions about requesting a coverage determination or filing an appeal or grievance, please call Customer Services at 1-888-247-4142 (toll-free), or for hearing impaired services TDD/TTY 1-888-247-4145.

For more detailed information, please review Section 6: Grievances and Appeals, of the plan Evidence of Coverage which outlines what to do to address member complaints:

Standard Plan - Evidence of Coverage
Enhanced Plan - Evidence of Coverage

What is generic drug substitution?

Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the U.S. Food and Drug Administration (FDA) to be as safe and effective as their name brand counterparts. As a result, the use of generics is encouraged through the Generic Drug Substitution Policy. The policy that is applicable to you is dependent upon your plan.

• Standard: If you have the Standard Plan and a prescribing physician allows for a generic drug to be substituted, but you elect to receive the brand, the member will be responsible for the entire cost of the medication.
  
  
• Enhanced: If you have the Enhanced Plan and a prescribing physician allows for a generic drug to be substituted, but you elect to receive the brand, the member will be charged the brand copayment or coinsurance amount plus the difference in cost between the brand and generic.

How do I make a request for a prior authorization or an exception to the quantity limit?

To request coverage of a prior authorization drug or an exception to the quantity limit for the member’s Blue Medicare Rx plan, you or your prescribing physician may call or submit a written request. If the request is received from you or your authorized representative, you will be asked to contact the prescribing physician and ask him to contact the plan with the clinical information necessary to make a decision or the plan can contact the prescribing physician for you.

When will I hear back with a decision?

We will review the prior authorization or quantity limit request and make a determination as soon as your health requires, but no later than 72 hours from the date and time we receive the clinical information from the physician necessary to review the request. You and your prescribing physician will be given notice of the coverage determination. Faster exception decisions are available if this 72-hour time frame could seriously harm your health or ability to function.

If the decision is not in your favor, the notice will be given by phone followed within three days by a written notice that will tell you how to pursue your appeal rights if you are dissatisfied with our decision.

Medication therapy management program

Members enrolled in the Blue Cross and Blue Shield of North Carolina (BCBSNC) Blue Medicare Rx plan may be eligible for the medication therapy management program (MTMP), in accordance with CMS requirements. The purpose of the program is to provide medication therapy management services to targeted Blue Medicare Rx members. These services are designed to ensure that covered Part D drugs are appropriately used to optimize therapeutic outcomes by improving medication use and reducing the risk of adverse drug events, including adverse drug interactions. The MTMP is developed in cooperation with licensed and practicing pharmacists and physicians.

Who is eligible for the MTMP?

Individual members eligible for the MTMP services must meet all three criteria below:

• Have multiple chronic diseases, such as diabetes, asthma, hypertension, hyperlipidemia, and congestive heart failure,
• Must have filled multiple Blue Medicare Rx covered medications, and
• Are likely to incur annual costs for covered Blue Medicare Rx medications that exceed $4,000 annually.

How will eligible members be identified?

Targeted members will be identified by the Pharmacy Benefit Manager (PBM) through prescription claims information. The PBM will provide a list of identified and eligible members to BCBSNC.

Medicare beneficiaries who meet the criteria below will be identified for MTMP services:

• Have at least 5 chronic conditions, with at least 2 of the following: hypertension, high cholesterol, congestive heart failure, diabetes, asthma
• Have claims for at least 6 different covered Blue Medicare Rx medications during a 12- month period or less based on receipt of claims data. Both chronic and acute medications are considered in the evaluation process.
• Will be likely to incur a minimum threshold of $4,000 in annual drug costs for covered Blue Medicare Rx medications.

How do eligible beneficiaries enroll?

Eligible members will be mailed an invitation to participate in the MTMP. Participation in the program is voluntary.

What happens once you enroll in the program?

• Members who agree to participate will be contacted by a nurse by phone. Services available include medication education, safety, adherence, and review of medical condition associated with the medication therapy.
• Members will have the option of speaking directly with a plan pharmacist, as appropriate.
• The member and or prescribing physician(s) will be notified of potential adverse drug events and interactions, and patterns of over-use or under-use of medication
• Members may receive educational materials via the mail.

What are the goals of the program?

• Educate members regarding their medications
• Increase adherence to medication therapy
• Identify and prevent medical complications related to medication therapy

Members should refer to their Evidence of Coverage for more details on the MTMP.