Pharmaceutical Management
Last Updated: Friday, October 25, 2024
Pharmaceutical Management (Clinical Management Programs) is designed to safeguard patients from potentially harmful drug interactions and side effects, optimize clinically appropriate therapy, promote appropriate prescription drug utilization and promote compliance with recommended drug quantity, dosage and intended use of product. These programs bring together every individual or entity involved in the management and delivery of pharmaceutical care: plan sponsor, physicians, members, and pharmacists. The programs are administered across all lines of business and are seamless across both retail and home delivery prescription drug benefit programs. These programs achieve their goals by:
- Identifying specific prescribing situations that may represent inappropriate utilization based on nationally-recognized clinical practice guidelines or manufacturer's recommended dosages.
- Providing the appropriate clinical interventions and follow up necessary with physicians and patients to foster more appropriate and effective use of prescription therapy.
Pharmaceutical Management Programs
Pharmaceutical management programs include the following:
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Drug Utilization Review (DUR)
Concurrent/Prospective Drug Utilization Review (DUR)
- Health and safety program that performs online, real-time drug utilization analysis at the point of prescription dispensing to evaluate the incoming therapy against a series of predetermined safety standards.
- Designed to reduce wasteful medical spending through avoidance of unnecessary emergency room utilization, hospitalizations, and urgent care visits by identifying and prompting for correction of clinical safety concern(s).
Retrospective Drug Utilization Review (DUR)
- Designed to initiate changes that help improve patient safety and correct important errors in care. Retrospective DUR evaluates a prescription against a patient’s prescription history and evidence-based guidelines to alert the prescribing physician to important, drug-specific, patient-specific health and safety issues.
- Identifies medication conflicts and the potential for inappropriate utilization.
Quantity Level Limit Policy
To view policies, view Pharmacy Policy Search by clicking the link below.
Prior Authorization
- Prior authorization may be required for certain medications. This means that Highmark will need to approve use of the medication before it is covered.
- Medications that require prior authorization include ones that may be misused or abused, should only be used in specific situations, could be unsafe when combined with other medications, or have alternatives available.
To initiate a prior authorization request, complete the Prescription Drug Medication Request Form and fax to the number on the form.
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Effective July 1, 2024, West Virginia Law (Senate Bill 267) mandates the electronic submission of prior authorization requests. For this reason, Highmark removed West Virginia prior authorization forms from the Provider Resource Center (PRC). All prior authorization requests must now be submitted to Highmark via our provider portal (Availity®)
To search for drugs and their prior authorization policy, select the Pharmacy Policy Search.
Process for Requesting Drug Coverage From a Pharmaceutical Management Program
Pharmaceutical management procedures encompass programs such as prior authorization, managed prescription drug coverage (MCxC), and Formulary Management. Physicians may request coverage for a product from any of the programs included on the following page:
Process for Requesting Drug Coverage From a Pharmaceutical Management Program
Changes and updates to all clinical management programs are distributed bi-monthly through the Formulary Update, which is distributed to all network providers.
Related Links
Additional information on Prescription Drug Programs can be found in the Highmark Provider Manual - Chapter 4, Unit 6.
