Here are some answers to frequently asked questions about our members' pharmacy benefits.
With Quality Care Dosing, we electronically check prescription medications before they’re filled to ensure that the quantity and dosage is consistent with the recommendations of the Food and Drug Administration (FDA) and others.
Prescriptions that do not meet recommendations may be modified in two ways:
- Dose Consolidation—Taking two or more pills a day of a medication that could be replaced with one pill that provides the same full day’s dosage. Dose consolidation can aid in the member’s compliance with their medication.
- Monthly Dosing—You may be taking a monthly quantity of medicine that exceeds the amount recommended by the FDA or other accepted clinical practice guidelines.
A Quality Care Dosing override can be submitted if you believe it’s clinically necessary for an exception to the guidelines.
Your patient can continue to take his or her medication as you prescribed it unless otherwise noted in medical policy 621A, Quality Care Dosing (QCD) Guidelines.
We consider a variety of factors, including: whether a drug is a generic or a brand name; whether the drug is unique; whether there are clinically appropriate alternatives to a drug; the drug's cost-effectiveness; and the drug’s FDA indications.
Our Pharmacy and Therapeutics (P&T) Committee, comprised of practicing physicians and pharmacists throughout the state, acts as an advisory committee for our pharmacy program. The program obtains recommendations from the P&T Committee and various other sources regarding many aspects of the drugs. We review this input and ultimately make the final tier decision.
