Quality Assurance and Utilization Management

Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits for our plans to help us provide quality coverage to our members:

• Prior Authorization: We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from us before you fill your prescription. If your doctor doesn’t get approval, we may not cover the drug. View our prior authorization criteria (pending CMS approval).
• Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we’ll cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A doesn’t work for you, we’ll then cover Drug B. View our step therapy criteria (pending CMS approval).
• Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
• Generic Substitution: When there's a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the Drug Formulary. If your drug is subject to one of these additional restrictions or limits, and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

Drug Utilization Review

We conduct drug utilization reviews for all our members to make sure that they’re receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

• Possible medication errors
• Duplicate drugs that are unnecessary because you’re taking another drug to treat the same medical condition
• Drugs that aren’t safe or appropriate because of your age
• Possible harmful interactions between drugs you’re taking at the same time
• Drug allergies
• Drug dosage errors

If we identify a medication problem during our drug utilization review, we’ll work with your doctor to correct the problem.

Learn more about the safe use of opioid pain medications (Updated 10/01/2022).

Drug Transition Supply Policy

You may be able to get a temporary supply under certain circumstances. The plan can offer a temporary supply of a drug to you when your drug isn’t on the drug list or when it's restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:
   • The drug you've been taking is no longer on the plan’s drug list.
   • Or—the drug you've been taking is now restricted in some way (Chapter 5, Section 4 of the EOC talks about restrictions).
2. You must be in one of the situations described below:
   • For those members who are new or who were in the plan last year and aren’t in a long-term care (LTC) facility:
     • We’ll cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new, and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be a maximum 30-day supply. If your prescription is written for fewer days, we’ll allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
   • For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:
     • We’ll cover a temporary supply of your drug during the first 90 days of your membership in the plan if you’re new, and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be a maximum 31-day supply. If your prescription is written for fewer days, we’ll allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
   • For those members who have been in the plan for more than 90 days, and reside in a long-term care (LTC) facility and need a supply right away:
     • We’ll cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
   • Members who have a change in level of care (setting) will be allowed up to a one-time 31-day transition supply per drug.

View our Transition Policy (Updated 05/12/2026).

Medication Therapy Management Program

View information about our Medication Therapy Management Program.

Low Income Subsidy (LIS) Information

To learn more about what information is needed to have your records immediately updated to reflect that you qualify for “extra help” (low income subsidy).

Part D sponsors must provide access to Part D drugs at the correct LIS cost-sharing level when presented with evidence of LIS eligibility. Learn more about CMS’ “Best Available Evidence” (BAE) policy.

Please consult the Summary of Benefits and the Evidence of Coverage for other important enrollment and membership information. Medicare beneficiaries may also enroll in BayCarePlus through the CMS Medicare Online Enrollment Center located at Medicare.gov.

Medicare Prescription Payment Plan

Are you struggling to deal with high prescription drug costs? The Medicare Prescription Payment Plan can help. This is a payment option that helps you manage your out-of-pocket costs for covered Part D prescription drugs by spreading them across the calendar year (January–December).

As a BayCarePlus member, if you select this payment option, you’ll receive a monthly bill from Scripius Medicare to pay for your prescription drugs (instead of paying the pharmacy). This plan is available to anyone with a Medicare drug plan or Medicare health plan with drug coverage (like Medicare Advantage Prescription Drug plan). It’s completely voluntary and there’s no cost to participate.

Learn more about the Medicare Prescription Payment Plan