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Prior Authorization Criteria

Step Therapy Criteria

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At Clever Care, we put members’ health and safety first. As part of our Medicare Part D plan, Clever Care offers QA and UM programs at no extra cost to Part D members. These programs are designed to ensure the safe and appropriate use of prescription medications covered under Medicare Part D. The programs help identify potential risks and opportunities to improve your medication therapy.

Quality assurance (QA)

In this program, every time a prescription is dispensed, it is reviewed for:

• Age/gender-related contraindications
• Over-utilization (e.g., early refill) and underutilization
• Clinically significant drug-drug interactions
• Incorrect drug dosage or duration of drug therapy
• Therapeutic duplication
• Inappropriate or incorrect drug therapy
• Patient-specific drug contraindications
• Abuse or misuse

This program also periodically reviews claims data.

Utilization management (UM)

This program consists of three parts, and is designed to encourage the safe, appropriate, and cost-effective use of Medicare Part D prescription drugs.

Prior authorization (PA) A PA requirement means the member, or their doctor must get approval before your medication is covered at your pharmacy.

Step therapy (ST) A ST requirement means you must first try one drug to treat a medical condition before another drug will be covered for that same condition.

Quantity limits (QL) A Quantity Limit requirement limits the amount of a drug that will be covered with prior approval.

Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Medicare Part D plan.

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program.

MTM is a service offered by Clever Care of Golden State at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit.  This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.

To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program.  Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

You must meet ALL of the following criteria to qualify to participate  in Clever Care’s MTM program,

1. Have at least 3 of the following conditions or diseases:
   • chronic heart failure, diabetes, dyslipidemia, hypertension, asthma, or chronic obstructive pulmonary disease, AND
2. Take at least 8 covered Part D medications, AND
3. Are likely to have medication costs of covered Part D medications greater than $4,376 per year.

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:

1. 1. Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, your caregiver, your pharmacist, and/or your doctor if we detect a potential problem.
   2. Comprehensive medication review: at least once per year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided to you confidentially via telephone by pharmacies operated by Tabula Rasa HealthCare. The CMR may also be provided in person or via telehealth at your provider’s office, pharmacy, or long-term care facility. If you or your caregiver are not able to participate in the CMR, this review may be completed directly with your provider. These services are provided on behalf of Clever Care Health Plan. This review requires about 30 minutes of your time. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors. This summary includes:
      • Medication Action Plan (MAP): The action plan has steps you should take to help you get the best results from your medications.
      • Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way.
      1.  

The Personal Medication List can help you and your health care providers keep track of the medications you are taking.

If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact Customer Service at  1-833-388-8168 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, and 8 a.m. to 8 p.m., weekdays, from April 1 through September 30.  Messages received on holidays or outside of our business hours will be returned within one business day.

Coverage Determination

A coverage determination is an initial coverage decision made by Clever Care regarding your Medicare Part D prescription drug. Coverage determinations you can request about your Part D drugs include:

• You can ask whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the Plan’s List of Covered Drugs but requires our approval before it is covered.)
• You can ask us to pay for a prescription drug you already bought.
• You can ask us for an exception. (If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an “exception.”) Examples include:
  • Asking for coverage of a drug that is not on the drug list
  • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
  • Asking us to remove the extra rules and restrictions on the Plan’s coverage for a drug such as:
    • Being required to use the generic version of a drug instead of the brand name drug
    • Getting plan approval in advance before we will agree to cover a drug for you
    • Quantity Limits

Important Information to Know About Asking for Exceptions

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

What to Do

You (or your representative or your doctor or other prescriber) may use the form below to submit your request for a Part D Coverage Determination.

Medicare Prescription Drug Determination Request Form

Please note: If you do not use this form, you will need to provide us the same information indicated in the form so we can process your request in a timely manner.

To start your Part D Coverage Determination request you (or your representative or your doctor or other prescriber) should contact Medimpact at (800) 926-3004 (TTY: 711).

• You may Fax your request to: (858) 790-6060 (Attention: Medicare Reviews)
• You may mail your request to:

MedImpact Healthcare Systems, Inc.
PO Box 509108
San Diego, CA 92150-9108

For additional assistance with making your Part D Coverage Determination request you may call our Customer Service Department.

Refer to your Evidence of Coverage, Chapter 9, Section 6 to find out more about the Part D Coverage Redetermination Process.

CMS created the “best available evidence” policy in 2006 requiring plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information was not accurate.

CMS continues to require Part D plans to rely on best available evidence and considers it best practice for the Part D plans to work with pharmacies to resolve these issues at point-of-sale when beneficiaries present with appropriate evidence of correct low-income status.

For more information call Customer Service or visit the CMS website