We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.
We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:
- Possible medication errors.
- Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
- Drugs that may not be safe or appropriate because of your age or gender.
- Certain combinations of drugs that could harm you if taken at the same time.
- Prescriptions written for drugs that have ingredients you are allergic to.
- Possible errors in the amount (dosage) of a drug you are taking.
If we see a possible problem in your use of medications, we will work with your doctor to correct the problem.
Piedmont Medicare Advantage (PPO) uses different types of restrictions to help our members use drugs in the most effective ways. For example:
Restricting a brand name drug when a generic version is available
Generally, a “generic” drug works the same as a brand name drug and usually costs less.
For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. When a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available, However, if your provider has told us the medical reason that the generic drug will not work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drugs.
This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug.
For certain drugs, we limit the amount of the drug that you can have for health and safety reasons.
For drugs with quantity limits or those requiring step therapy, CLICK HERE
Piedmont Medicare Advantage is a PPO plan with a Medicare contract. Enrollment in Piedmont Medicare Advantage depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
H1659_Web2018 Approved 10112017
Last updated 10/16/2017