Utilization Management

What is Utilization Management (UM)?
The term Utilization Management, or 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 Blue Cross Blue Shield of New Jersey, ensure patients receive appropriate services and medications at the right time and for the right duration of time.

UM programs help with things like:

  • 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 Blue Cross Blue Shield of New Jersey (BCBSNJ) uses the following 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)

Aspects of the Pharmacy UM Program

What is Prior Authorization & Medical Necessity Determination (PA/MND)
Certain drugs require Prior Authorization or Medical Necessity Determination (PA/MND) before coverage is approved.

The PA/MND process is designed to ensure that only prescription drugs that are medically necessary and appropriate 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 and helps keep the cost of prescription drug therapy affordable for you. Learn more on our Prior Authorization page.

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


What are 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.

What is a Drug Utilization Review (DUR)?
Since a member can be seen by different doctors and obtain medication through a variety of pharmacies, DURs help prevent drug safety issues and identify any gaps in care. Our online claims processing computer system allows immediate review and verification of eligibility, prescription drug coverage, drug-drug interactions, and restrictions. We are also able to integrate pharmacy and medical claims to thoroughly identify any gaps in care or safety concerns. We provide written reports to member's treating physicians to fully inform them of any issues that have been identified.