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Part D Quality Assurance

Drug management programs

AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid plan) has created special programs to help you access your prescriptions safely, at the lowest cost to you.

Utilization management

For some prescription drugs, AmeriHealth Caritas VIP Care Plus has extra requirements for coverage or limits on coverage. This is called utilization management. These requirements and limits help ensure that members use these drugs in the most effective way to help control drug costs. They were designed by a team of providers and pharmacists.

Examples of utilization management tools are:

  1. Prior authorization
    AmeriHealth Caritas VIP Care Plus requires you to get prior authorization for certain drugs. This means that prescribers 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, AmeriHealth Caritas VIP Care Plus 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 your medical condition, we may require your provider 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 AmeriHealth Caritas VIP Care Plus that you must take the brand-name drug and has obtained a prior authorization.

Medication therapy management (MTM)

AmeriHealth Caritas VIP Care Plus has partnered with PerformRxSM to offer medication therapy management (MTM) programs at no additional cost for members who:

  • Have multiple medical conditions.
  • Are taking many prescription drugs.
  • Have high drug costs.

A team of pharmacists and providers developed these MTM programs to help provide better prescription drug coverage for plan members. For example, these programs help us ensure that our members are using the proper drugs to treat their medical conditions and help AmeriHealth Caritas VIP Care Plus spot possible medication errors.

AmeriHealth Caritas VIP Care Plus offers MTM programs for members who meet certain criteria. As an AmeriHealth Caritas VIP Care Plus member, we may notify you of being enrolled in the program. AmeriHealth Caritas VIP Care Plus hopes that you will participate in any program offered to help you manage your medications. Remember, you do not need to pay anything extra to participate. If you are selected as an eligible participant for an MTM program, AmeriHealth Caritas VIP Care Plus will send you information about the specific program, including how to disenroll if you choose not to take part.

To learn more, or to obtain MTM documents, call PerformRx at 1-888-349-0501 (TTY/TDD 1-888-765-6351) 8:30 a.m. to 5 p.m., Monday through Friday

2019 medication therapy management

These programs may have limited eligibility criteria and are not considered a benefit; they are available for the following conditions:

1. Having at least three of the following disease states:

  • Asthma.
  • Chronic heart failure (CHF).
  • Chronic obstructive pulmonary disease (COPD).
  • Chronic and/or disabling mental health conditions.
  • Diabetes.
  • Dyslipidemia.
  • End-stage renal disease (ESRD).
  • Hypertension.
  • Osteoporosis.
  • Rheumatoid arthritis.

2. Being on at least five different medications from the following list to treat those disease states:

  • Angiotensin-converting enzyme (ACE) inhibitors.
  • Angiotensin II receptor blockers (ARBs).
  • Antidepressants.
  • Antihyperlipidemics.
  • Antihypertensives.
  • Antipsychotics.
  • Beta blockers.
  • Bisphosphonates.
  • Bronchodilators.
  • Calcimimetic.
  • Calcium channel blockers.
  • Cardiac Glycosides.
  • Colony stimulating factors.
  • Disease-modifying anti-rheumatic drugs (DMARDs).
  • Diuretics.
  • Glucocorticosteroids.
  • Glucagon-like peptide-1 receptor agonists.
  • Inhaled corticosteroids.
  • Insulins.
  • Neprilysin Inhibitors.
  • Non-steroidal anti-inflammatory drugs (NSAIDs).
  • Oral hypoglycemics.
  • Phosphate binders.
  • Selective serotonin reuptake inhibitors (SSRIs).
  • Vitamin D analogs.

3. Being likely to incur drug costs of $4,044 per year.

To learn more, call PerformRx at 1-888-349-0501 (TTY 1-888-765-6351), 8:30 a.m. to 5 p.m., Monday through Friday.

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