Process Group
Utilization Management
Objective
Validate appropriate use of prescribed medicines
Guard against over-use, under-use and misuse of pharmaceutical therapies and take action to resolve. (Note: PBM is an integral part of UM procedures. It is singled out here in this process matrix because of the inherent threat from escalating drug prices, misuse of drug formulary, and overprescribing habits on the part of some providers)
Input
Output
Report on provider utilization of pharmaceuticals versus alternative benchmarks that are culturally accepted
Letters to provider based on alternative therapies or use of generic drugs
Lock in member to specific pharmacy
Measurable Outcomes
X time period report (quarterly) which describes in detail prescribing behavior usually by region, by medical specialty, by facility
Reduction of cost of pharmacy benefits
Adherence to use of lower cost medications (generic substitutions)