Utilization Management

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.

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. 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

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). Certain drugs require PA/MND before coverage is approved.
  • Dispensing Limits (including age and gender limits). To arrive at limits for certain medications, Horizon BCBSNJ follows recommendations by the FDA, coupled with our analysis of prescription dispensing trends and standard clinical guidelines.
  • Drug Utilization Review (DUR). Because 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 system allows immediate review and verification of eligibility, prescription drug coverage, drug-to-drug interactions and restrictions. We then provide written reports to all the member’s treating physicians.

About adherence programs

Adherence programs help ensure members derive the most benefit from their prescriptions by taking them correctly. We help members overcome the many factors that could cause them to take a medication improperly. These include:

  • Side effects of the medications
  • Complexity of the medication regimen
  • Cost of the medication
  • Belief the medication is not needed
  • Relationship between the patient and their health care professional

Our goal is to understand the typical barriers to medication adherence and create strategies to address those barriers. These strategies can include providing special pill boxes, reminder packaging and nurse coaching.