Medicare Plans

Programs to Ensure Safe and Effective Use of Medications

Network Health or its delegates will use procedures and software that seek to promote the cost effective and safe use of medications.

This is accomplished with processes like step therapy, prior authorization and tiered cost-sharing. In addition, we have specific programs to help prevent the over and under utilization of drugs.

For more information about these programs, call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. - 8 p.m. (TTY 800-947-3529).

Utilization Management and Quality Assurance Procedures

At Network Health, we use procedures and software to ensure the most cost-effective and safe medication therapy. Some of these procedures include step therapy, prior authorization and tiered cost-sharing. In addition, there are specific programs available to help prevent the overuse or under use of medications. And, we offer a Medication Therapy Management Program to help members who take multiple medications.

Here are some of the procedures we have in place.

Requirements for Network Pharmacies

  • Ensure counseling is offered to members, when appropriate.
  • Implement a method of maintaining up-to-date member information, such as, but not limited to, member demographic information or allergy information (drug and food).
  • Meet the minimum standards for pharmacy practice as established by the State.
  • Review the concurrent drug utilization review systems. This requires pharmacies to review the prescribed drug therapy before giving the prescription to a member. Screening should include, but not be limited to, the following.
    • Therapeutic duplication
    • Age-related contraindications
    • Overuse and under use
    • Drug interactions with each other
    • Incorrect drug dosage or time instructed to take a drug
    • Drug-allergy complications
    • Clinical abuse/misuse

Retrospective Drug Utilization Review Systems

  • We use a system designed to ensure the ongoing examination of claims data and other records on a regular basis. Computerized drug claims processing and information retrieval systems are used to identify patterns of inappropriate or medically unnecessary care, or risks associated with specific drugs or groups of drugs.
  • As part of Network Health's quality improvement process, medication error reports are reviewed to identify trends in medication errors and find opportunities for improvement.
  • For safety information related to Medicare, we provide the Centers for Medicare and Medicaid Services (CMS) information about their quality assurance measures and system upon request.

For more information

If you have any questions about these specific programs, call our customer service department at 800-378-5234 (TTY 800-947-3529) Monday–Friday,  from 8 a.m. to 8 p.m. 


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.