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Plans tread lightly when sharing utilization criteria online


There are pros and cons of posting UM criteria online. Information can be helpful, but it can also open up a can of worms.

Determining the precise point at which there is too much information remains an ongoing struggle for health plans as they try to balance the amount of detail they provide their networks about pharmacy utilization management (UM) requirements.

"By providing the pharmacy utilization management criteria, there will be no doubt as to the guidelines developed by a plan's P&T committee about formulary, prior authorization and step therapy," says Marissa Schlaifer, director, pharmacy affairs for the Academy of Managed Care Pharmacy (AMCP), a national professional society. "Sharing this kind of information is part of the drive toward transparency by the industry. If the criteria are available, providers will not waste time prescribing medications they know will not be approved except under certain circumstances."


Michael Brodeur, head of formulary development and pharmacy clinical policies for Aetna Pharmacy Management, says posted criteria have made it easier for providers and members to retrieve specific information on requirements associated with prescribing certain prescriptions, quantity limits and its formulary. This way, he says, they know which drugs can be prescribed under the benefit.

Brodeur studied the effect the posted criteria had on approval and denial rates and found that the numbers stayed consistent over nine years-about a 70% approval rate and 30% for denials. He says, however, that if physicians know what is expected and explain restrictions to their patients, there is bound to be a higher approval rate.

To communicate its policies for both its commercial population and for Part D, Aetna relies on electronic Pharmacy Clinical Policy Bulletins (PCPBs). Brodeur says that bulletins are easy to use by physicians, although they can be highly detailed. They identify specific therapeutic drug classes and include enough depth to be understood and applied by the internal precertification unit to process requests, but may have more detail than an external physician or member would need.

The bulletins determine medical necessity based on currently available clinical information, such as outcome studies, peer-reviewed medical literature, evidence-based medicine and positions of leading national professional health organizations. The preferred drug list, along with exclusions and restrictions, such as quantity and age limits, step therapy and precertification, are also included.

For example, a PCPB calls for precertification for Zocor, a statin, but goes on to say that the drug is medically necessary for patients who meet certain criteria, such as a contraindication or intolerance for fenofibrates, a cholesterol-lowering drug in the fibrate class.

For Medicare beneficiaries, the site includes a full list of medications, detailing covered uses, exclusion criteria, required medical information, age and prescriber restrictions and coverage duration. Bordeur says that Aetna's policies fall into the middle of the pack in terms of their level of strictness; however, when it comes to cost containment, Aetna leans toward a more restrictive stance.


Helen Sherman, chief pharmacy officer for Portland, Ore.-based Regence, says that criteria on Regence's site provides a comprehensive overview of coverage policies and their rationale, along with a price guide; prior authorization and quantity level limits for selected medications; alternatives to non-formulary drugs; information on generics; a comparison shopping guide; and a consumer section. The consumer information includes educational summaries on drug choices, benefits and risks written in layperson's terms.

Sherman says that guidelines on the CMS Web site are more limited and must follow a specific format.

"The CMS Web site will note whether there are UM restrictions, but a Medicare D beneficiary will then have to go to the Regence Web site to obtain specific information. We want to be able to provide more information than CMS requires," she says.

According to the site, medication policy "is to provide a guide to coverage and is not intended to dictate to providers how to practice medicine." The criteria have been "developed through consideration of medical necessity, generally accepted standards of medical practice and review of medical literature and governmental approval process."

Although Sherman says that Regence has long deliberated over the repercussions of reporting UM criteria publicly, she has found that the knowledge has resulted in fewer rerequests for certain medications and appeals, while member satisfaction has risen as consumers better understand why a drug may or may not be covered.

Sherman says Regence's commitment to posting the criteria has served the plan well by providing consistent information, which "can stand public scrutiny by everyone."

Sherman agrees with Schlaifer and Brodeur that by providing too much information, a plan may run the risk of opening its doors to providers who may try to beat the system. However, the resources it takes to maintain updated policy information may prevent some plans from following through.

Mari Edlin is a frequent contributor to MANAGED HEALTHCARE EXECUTIVE. She is based in Sonoma, Calif.

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