Utilization Management (UM)

Utilization Management (UM) programs are geared toward improving overall health care outcomes by ensuring members receive the right care or medications at the right time – and for the right duration of time.

The term UM refers to a variety of health care programs and activities. In general, UM deals with collecting, monitoring and studying patient data to see what’s working and what needs to change to improve health care outcomes overall. It also helps health insurers, like Horizon BCBSNJ, ensure patients receive appropriate services and medications at the right time and for the right duration of time.

For example, UM programs help with:

  • Timeliness of services
  • Length of stay in a hospital and proper discharge
  • Patient recovery times
  • Proper medication prescribing and adherence
  • Health care planning

Our members benefit from UM because these programs help us continuously review and monitor how we care for patients, while helping physicians and other health care professionals learn from relevant data, see statistical trends and find areas for improvement when necessary.

About our Pharmacy UM Program

Horizon BCBSNJ uses the following criteria to help ensure access to medically necessary and appropriate, cost-effective drug therapy:

  • Prior Authorization & Medical Necessity Determination (PA/MND)
  • Dispensing Limits (including age and gender limits)
  • Drug Utilization Review (DUR)

Prior Authorization & Medical Necessity Determination (PA/MND)

Certain drugs require Prior Authorization & Medical Necessity Determination (PA/MND) before coverage is approved. The PA/MND process is designed to assure only medically necessary and appropriate prescription drugs are approved for coverage. PA/MND also:

  • Encourages appropriate use of certain prescription drugs
  • Promotes generally accepted treatment protocols
  • Actively monitors prescription drug use that may have serious side effects
  • Helps keep the cost of prescription drug therapy affordable

Drug dispensing limitations and Drug Utilization Review (DUR) are part of PA/MND.

Drug dispensing limitations

Certain prescription medications have specific dispensing limitations for quantity, age, gender and maximum dose. To arrive at these quantity or safety limits, Horizon BCBSNJ follows recommendations by the FDA, coupled with our analysis of prescription dispensing trends and standard clinical guidelines. These dispensing limitations are drug specific and are designed to provide a safe and effective amount of medication to our members.

Drug Utilization Review (DUR)

Since a member can be seen by different doctors and obtain medication through a variety of pharmacies, DURs help prevent potential drug interactions.

Our online claims processing computer system allows immediate review and verification of eligibility, prescription drug coverage, drug-to-drug interactions and restrictions. We provide written reports to all the member’s treating physicians to fully inform them of the activities of other prescribers.