Medication Quality Assurance
Our plan has Medication Quality Assurance programs to help you receive safe and timely care.
Getting your medications filled on time and taking them as your doctor directs is an important part of staying healthy. Not taking your medication on time can cause your health to get worse. There are some easy ways we can help you stay on track and feeling well.
- Call us, your doctor or pharmacy about drugs to treat your condition that cost less.
- Ask your pharmacy if they offer 90-day refills or home delivery to save you time.
- Check with your pharmacy about auto refills to remind you when your order is ready.
- Save trips to the pharmacy by having all your drugs filled on the same day.
- For drugs you take regularly, sign up for our mail order pharmacy service to ship orders to your home.
- Use a pill box and keep it handy to remind you to take your drugs on time.
If you need help getting your medications, contact Member Services.
Drug and Utilization Review Programs
Our Drug and Utilization Review Programs include a review of current and past claims. When a pharmacy submits your prescription for coverage, we look for:
- Age related problems
- Gender related problems
- Overuse and underuse
- Issues with other drugs you take
- Issues with a disease you have
- Wrong drug dosage
- Wrong length of therapy
- Drug/allergy issues
- Abuse or misuse
For questions about our programs contact Member Services.
Drug Management Program
Our Drug Management Program monitors our members’ safe and effective use of opioid medications like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine.
Taking opioid drugs can help with certain types of pain after an injury or surgery. Taking them also comes with serious risks like addiction, overdose and death. These risks can increase if you take high doses, or take opioids with certain other drugs like benzodiazepines (Xanax®, Valium®, Klonopin®) for anxiety or sleep.
The program’s goal is to help you, your doctor and your pharmacy ensure that you are prescribed the correct drugs for pain and you take them safely.
When you fill a prescription, your pharmacist will review all the drugs that you take to check for:
- Potentially unsafe amounts
- Interactions with other drugs like benzodiazepines
A new prescription may be limited to a seven-day supply or less. This limit does not apply if you have been taking an opioid.
If your prescription can’t be filled, your pharmacy will give you a notice explaining how to ask us for a coverage decision. If your health requires it, you can ask us for a fast coverage decision. You also can ask us for an exception to our rules before you go to the pharmacy so you’ll know if we will cover your drug.
How our program works
If you get an opioid drug from more than one doctor, we may talk with your doctors to make sure you need the drug and that you’re using it safely. If we decide your use of the drug isn’t safe, we may limit your coverage. For example, to better coordinate your care, we may require you to get the drug only from certain doctors or fill them at certain pharmacies.
Before we place you in our program, we will send you a letter to explain our review of your drug history. You then can tell us which doctors or pharmacies you prefer to use to get your drugs. If we limit your coverage, we will send you another letter to explain what you and your doctor can do to appeal our decision.
Our program does not apply to you if you have cancer, sickle cell disease, or if you receive hospice, palliative or end-of-life care, or if you live in a long-term care facility.
Your Provider Can Help
Talk with your doctor about all of your pain treatment options. Then decide what is right for you. You could take other drugs or do other things to manage your pain with less risk.
Contact Member Services if you have questions about our Drug Management Program.
For more information on safe and effective pain management visit:
- The Centers for Disease Control and Prevention (CDC) resources at https://www.cdc.gov/drugoverdose/patients or https://www.cdc.gov/drugoverdose/epidemic
- The U.S. Department of Health and Human Services website
- The Medicare.gov website, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Get information 24 hours a day, 7 days a week.
MeridianComplete has established a Quality Assurance program that is designed to ensure our members receive high quality, medically appropriate and cost effective health care. The program monitors and evaluates the quality and appropriateness of services provided. In addition, the program provides the framework to pursue opportunities for improvement and problem resolution.
MeridianComplete has also developed Drug Utilization Review (DUR) systems to identify drug-drug interactions, unusual dosage of a particular drug, concerns with the age and/or gender of the consumer and various other factors.
The MeridianComplete DUR system evaluates the appropriateness of the prescription at the point-of-sale by utilizing the following safety edits:
- Drug-Drug: This edit will alert the pharmacy if there is another medication that interacts with the medication being filled.
- Therapeutic Duplication: This edit will alert the pharmacy if there is another medication that is considered a therapeutic duplication.
- Dose Optimization: This edit will alert the pharmacy if the dose requested is outside of the normal dosing and duration/range of therapy guidelines.
- Drug-Age: This edit will alert the pharmacy if the drug should not be used for consumers in a specific age range, based on FDA regulatory guidelines.
- Drug-Gender: This edit will alert the pharmacy if the drug should not be used for consumers of a specific gender.
- Drug-Pregnancy: This edit will alert the pharmacy if the drug should not be used for female consumers of reproductive age.