Drug Benefit

Utilization Management (UM) is a process that is part of your health plan and is not considered a separate benefit. UM helps to make sure that you are getting the right drugs — all while helping to make medicine more affordable.

UM is made up of several different programs

Health plans call for UM on some medicines to keep you safe, by helping to make sure the medicines you take are prescribed by your doctor and used correctly. UM is made up of programs that include:

• Step Therapy helps lower costs through safe, less expensive drugs. This program uses a "step" approach with drugs for certain conditions. This means that you may have to first try a safe, lower-cost drug, or one that may be more clinically effective, before "stepping up" to a different drug.
  As a member of Vibra Health Plan, if your drug requires Step Therapy, your doctor must submit a Step Therapy Exception Form for approval. If the request is not approved, you have the option to appeal the coverage decision or you can purchase the drug at your own expense.
• Prior Authorization helps improve safety. Some drugs can be misused or overused, or may not be the best choice for your health condition. Prior authorization (sometimes called pre-approval) means that your medicine needs to be approved by your health plan before it will be covered.
  As a member of Vibra Health Plan, if your drug requires Prior Authorization, your doctor must submit a Prior Authorization Request Form for approval. If the request is not approved, you have the option to appeal the coverage decision or you can purchase the drug at your own expense.
• Quantity Limits helps to lower waste. This program controls how often or the amount you can get filled at once. These limits promote safe, cost-effective drug use. They also help reduce waste and overuse.
  As a member of Vibra Health Plan, if your drug has specific Quantity Limits, your doctor must submit a Quantity Limit Exception Form for approval of any amount over that limit. If the request is not approved, you have the option to appeal the coverage decision.
• Formulary Exceptions are required for some drugs. As a member, if your drug requires a Formulary Exception, your doctor must submit a Formulary Exception Form for approval. If the request is not approved, you have the option to appeal the coverage decision or you can purchase the drug at your own expense.