Utilization Management Requirements
Medication Management or Utilization Management Requirements are for certain prescription drugs with special rules that restrict how and when the plan covers them.
A team of doctors and pharmacists developed these requirements to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.
In general, our rules encourage you to get a drug that is safe and works for your medical condition. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option.
Please refer to our Commercial NavitusRx Formulary to determine specific drug coverage information.
How or Where can I see the changes to Prior Authorization or Utilization Management Criteria?
Certain medications may require prior authorization or other utilization management review to determine coverage under the member's pharmacy benefit. Members or their providers may be required to provide additional information to determine if the medication is covered under the member's pharmacy benefit. These changes can happen as often as on a monthly basis and are updated on our formulary and on the document accessible below to serve as a way for our members, providers, and other members of the healthcare team to review these updates, see the changes in prior authorization requirements or process, along with the date or time the changes will become effective.
- Review current updates to Utilization Management or Prior Authorization Criteria here.
- Review our formulary here.
- Review our prior authorization approval and denial rates for the previous calendar year here.
Examples of Utilization Management
Prior Authorization Program
Most pharmacy benefit plans include the Prior Authorization program. Prior authorization helps encourage the appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met.
Drugs requiring prior authorization are designated in the Formulary by "PA" (Prior Authorization) under the Restrictions information. These drugs require prior authorization before members can obtain them as a covered benefit. Drugs requiring prior authorization are subject to change. Please contact Navitus Health Solutions for a current list of drugs requiring prior authorization and for their coverage criteria. If prior authorization is required, the physician (or his/her representative) must call Navitus Customer Service at (866) 333-2757 or fax the request with supporting clinical information to Memorial Hermann Health Solutions pharmacy benefit manager at (855) 668-8552.
Download a Prior Authorization Request
Alternatively, you can visit the Navitus Provider Portal to find the Prior Authorization forms.
Quantity Level Limits
Some drug products may be subject to quantity level limits based on the drug manufacturer's packaging size or adopted clinical guidelines. These drugs are designated in the Formulary by "QL" (Quantity Limits) under the Restrictions information. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity level limits are subject to change.
Please contact Navitus Customer Service at (866) 333-2757 for more information.
Step Therapy Limits
In some cases, Memorial Hermann Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Memorial Hermann Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.
Please contact Navitus Customer Service at (866) 333-2757 for more information.
Additional Information
If you have questions about Utilization Management restrictions, such as Step Therapy or Prior Authorization, please call the Customer Service on the back of the member ID card.
Exceptions to Utilization Management Program
Members or providers can initiate an exception request, please call the Customer Service number on the back of your member ID card for additional information.
Providers can also call Navitus Customer Service at (866) 333-2757 or visit the Navitus Provider Portal.
For additional information, please see Pharmacy Benefits Information.