Part D Quality Assurance

Quality Assurance

AgeWell New York has created special programs to help you access your prescriptions safely.

Utilization Management

For some prescription drugs, AgeWell New York has extra requirements for coverage or for limits on coverage. The requirements and limits ensure that our members use these drugs in the most effective and safely way. Examples of utilization management tools are:

1. Prior Authorization

   AgeWell New York requires 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.

2. Quantity Limits

   For certain drugs, AgeWell New York limits the amount of the drug that we will cover per prescription or for a defined period of time.

3. Step Therapy

   In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the member’s medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

4. Generic Substitution

   When there is a generic version of a brand-name drug available, network pharmacies will automatically give you the generic version, unless your doctor has told AgeWell New York that you must take the brand-name drug and have obtained a prior authorization.

Non Part D Drugs (Exclusions)

Medicare only covers for some drugs or drugs categories; the drugs that are not covered are not considered part D drugs. In some cases Non Part D drugs may be referred as “exclusions”:

• Drugs used for cosmetic purposes or hair growth
• Fertility drugs
• Weight loss, weight gain or anorexia
• Drugs for symptomatic relief of cough or colds
• Non-prescription drugs
• Prescription vitamins or minerals
• Treatment for sexual or erectile dysfunction

You may also need to consider, that as a Medicare prescription Drug Plan we cannot cover a drug that will be cover under Medicare part A or B.

In addition, while a Medicare Prescription Drug Plan can cover off-label uses of a prescription drug, we cover the off-label use only in cases where the use is supported by certain reference book citations. Congress specifically listed the reference books that list whether the off-label use would be permitted. These compendia are: (1) American Hospital Formulary Service Drug Information; (2) United States Pharmacopoeia-Drug Information; and (3) the DRUGDEX Information System; and (4) Medscape. If the use is not supported by one of these reference books (known as compendia), then the drug would be considered a non-Part D drug and would not be covered by AgeWell New York.

Drug Utilization Review

We care about your safety, that’s why AgeWell New York reviews the drugs that you are taking to ensure that you are receiving the most appropriated and secure care. There are some members that receive prescription from more than one doctor. This program is especially important for them. The review is doing using claims data, we pay attention to issues such us:

• Duplication of drugs
• Drug dosage error or therapy duration
• Inappropriate medication
• Allergies
• Clinical use and misuse
• Over and under-utilization

Medication Therapy Management (MTM)

AgeWell New York Care has partnered with Clinical Support Services (CSS) to offer medication therapy management programs. Learn more about Medication Therapy Management.