Drug Management Programs

Quality assurance

First Choice VIP Care Plus (Medicare-Medicaid Plan) has created special programs to help you access your prescriptions safely at the lowest cost to you.

Utilization management

For some prescription drugs, First Choice VIP Care Plus has extra requirements for coverage or limits on coverage. This is called utilization management. These requirements and limits help ensure that members use these drugs in the most effective way to help control drug costs. They were designed by a team of providers and pharmacists.

Examples of utilization management tools are:

  1. Prior authorization
    First Choice VIP Care Plus requires you to get prior authorization for certain drugs. This means that prescribers will need to get approval from us before you fill your prescription. If they do not get approval, we may not cover the drug.
  2. Quantity limits
    For certain drugs, First Choice VIP Care Plus limits the amount of the drug that we will cover per prescription or for a defined period of time.
  3. Step therapy
    In some cases, we require you to first try one drug 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, we may require your provider to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
  4. Generic substitution
    When there is a generic version of a brand-name drug available, network pharmacies will automatically give you the generic version, unless your doctor has told First Choice VIP Care Plus that you must take the brand-name drug and has obtained a prior authorization.

Medication Therapy Management

First Choice VIP Care Plus has partnered with PerformRx℠, our pharmacy benefits manager, to offer medication therapy management (MTM) programs at no additional cost to our members who:

  • Have multiple medical conditions.
  • Are taking many prescription drugs.
  • Have high drug costs.

A team of pharmacists and doctors developed these MTM programs to help provide better prescription drug coverage for plan members. For example, these programs help us ensure that our members are using the proper drugs to treat their medical conditions. They also help First Choice VIP Care Plus spot possible medication errors.

First Choice VIP Care Plus offers MTM programs for members who meet certain criteria. As a First Choice VIP Care Plus member, we may notify you about enrolling in the program. First Choice VIP Care Plus hopes that you will participate in this program to help you manage your medications. Remember, you do not need to pay anything extra to participate.

If you are selected as an eligible participant for an MTM program, First Choice VIP Care Plus will send you information about the specific program, including how to disenroll if you choose not to take part. If you wish to join in the program, PerformRx will contact you by phone or mail with informational materials.

Our outreach to you should take less than 30 minutes to complete. You will be eligible for both the comprehensive medication review, which will be a review of all your medications and therapy programs, and a targeted medication review, which will target your specific conditions. We will provide you an overview of the MTM program, a personal medication list (PDF — November 22, 2024), a recommended to-do list (PDF — November 22, 2024) based on your medications and educational information based on the specific conditions which you have.

If you decide to participate in this program, we will also contact your primary care provider to discuss your current treatments to work to improve your conditions and outcomes. You will be able to get any information we get from our consultations with your providers.

Every three months, we will send you materials for you to review. We ask that you review this information and provide us any updates so that we are aware of your current information. In addition to requesting updated information, we will offer you a chance to have a comprehensive medication review. You may also receive extra information targeted at your specific conditions. These reviews can be helpful in reviewing your current drug treatment to ensure that you are receiving the best care.

To learn more, or to obtain MTM documents, call PerformRx at 855-327-0511 (TTY 1-888-765-6351) 24 hours, 7 days a week

2024 MTM programs

You are eligible for the Drug Management Program based on the Centers for Medicare and Medicaid Services (CMS) guidelinesThese programs may have limited eligibility criteria and are not considered a benefit; they are available for the following conditions:

Having at least three of the following disease states:

  1. Asthma
  2. Chronic and/or disabling mental health conditions
  3. Chronic heart failure (CHF)
  4. Chronic obstructive pulmonary disease (COPD)
  5. Diabetes
  6. Dyslipidemia
  7. End-stage renal disease (ESRD)
  8. Hypertension
  9. Osteoporosis
  10. Rheumatoid arthritis

Being on at least five different medications from the following list to treat those disease states:

  1. Angiotensin-converting enzyme (ACE) inhibitors
  2. Angiotensin II receptor blockers (ARBs)
  3. Antidepressants
  4. Antihyperlipidemics
  5. Antihypertensives
  6. Antipsychotics
  7. Beta blockers
  8. Bisphosphonates
  9. Bronchodilators
  10. Calcimimetic
  11. Calcium channel blockers
  12. Cardiac Glycosides
  13. Colony stimulating factors
  14. Disease-modifying anti-rheumatic drugs (DMARDs)
  15. Diuretics
  16. Glucagon-Like Peptide-1 Receptor agonists
  17. Inhaled corticosteroids
  18. Insulins
  19. Neprilysin Inhibitors
  20. Non-steroidal anti-inflammatory drugs (NSAIDs)
  21. Oral hypoglycemics
  22. Phosphate binders
  23. Selective serotonin reuptake inhibitors (SSRIs)
  24. Vitamin D analogs

Drug costs of $5,330 per year are likely to be incurred.

To learn more, or to obtain MTM documents, call PerformRx at 855-327-0511 (TTY 1-888-765-6351) 24 hours, 7 days a week

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Members 2024