Pharmacy Treatment Improvement Opportunities

In addition to our formularies, prescribing limits and restrictions, we promote quality of care by monitoring claims to improve outcomes and patient safety. CMS requires us to identify certain treatment opportunities and proactively address them with providers and members. Some of these are addressed through polypharmacy measures and others through drug-drug interactions through concurrent drug utilization review. Some of these medication issues factor into our Star rating scores.  

Medication Adherence  
We pay close attention to medication adherence for disease states such as diabetes, hypertension and hypercholesterolemia. We monitor medication adherence rates by reviewing pharmacy claims data, and if a member is non-adherent to their medications, we will address this with the member to see why the member is not taking their medication as prescribed.  

Statin Use in Diabetes  
The guidelines of several medical societies state that diabetics should be on a statin, regardless of whether they have high cholesterol or not, to prevent cardiac events such as heart attacks. We will alert prescribers when they have members with diabetes that are not on a statin.