Utilization Management Tools

Our pharmaceutical management procedures are integral in ensuring and promoting the utilization of the most clinically appropriate agent(s) to improve the health and well-being of our members.

To request an evaluation of a pharmaceutical that: is not on the PDL, has an age edit, exceeds established quantity limits, is a brand name when a generic exists, or requires a prior authorization or step edit, please submit a Drug Evaluation Review form.

Expedited requests and an emergency supply of medication will be completed within 24 hours. Refer to your Quick Reference Guide for the Pharmacy Services contact information. In the event your non-emergency DER request is denied, you have the right to submit an appeal.

For more information on coverage limitations and pharmacy utilization management tools, refer to your Provider Manual.