Utilization Management Tools
Utilization management tools are the methods Part D and Medicare Advantage plans use to control cost and promote appropriate use, principally prior authorization, quantity limits, and step therapy. They condition coverage of certain drugs or services on meeting plan criteria.
Definition
Utilization management tools are the methods Part D and Medicare Advantage plans use to control cost and promote appropriate use, principally prior authorization, quantity limits, and step therapy. They condition coverage of certain drugs or services on meeting plan criteria.
Why it matters
These tools can delay or redirect prescribed therapy, so clinicians should anticipate them and document the rationale needed for approvals or exceptions.
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