Part D Processes to Assure Quality
GHP has processes in place to assure that the medications received and the prescription process meet the quality standards of patient safety, medication effectiveness, and cost-effectiveness. These quality assurance processes include:
Formulary Development
The GHP formulary development process ensures there are available options for treatment in each therapeutic drug category. Considerations for addition to the formulary are related to effectiveness of the medication, medication safety, as well as the cost-effectiveness of the medication. Formulary drugs include all covered medications - generic and selected brand name medications. As a general rule, non-formulary medications are not covered under the GHP Part D benefit.
Requests for non-formulary medications must meet medical necessity criteria through the "exception process” in order to be covered under the member's prescription benefit.
Prior Authorization and Step Therapy Requirements
Step therapy requirements exist for the treatment of various medical conditions. This means that a set of recommended formulary medications for the condition must be tried before using non-formulary alternatives. If there are no alternatives in the formulary to be used for the condition, the "exception process" is in place to have GHP consider and decide whether approve a non-formulary alternative medication.
Your doctor must complete the “exception process” requirements demonstrating that you meet necessary medical criteria for the non-formulary medication.
Quantity Limits
Generally, there are quantity limits on the number of prescribed pills allowed per prescription. If members require more than recognized doses of medications per prescription, your doctor must complete the “exception process” demonstrating that you meet necessary medical criteria to receive a higher than expected number of doses of medication.
Medication Therapy Management Program and Medication Safety
Medication safety begins at the pharmacy when a prescription is filled. Each prescription undergoes a Drug Utilization Review (DUR) process in real time that assures the member’s safety with the written prescription. The DUR process includes a look at the prescription profile of the member and provides a safety alert to the pharmacy any time there is a the potential for a safety issue. Examples of safety alerts include alerts for dosage errors, a drug interaction with a drug you are currently taking, a drug allergy, or the prescription is a drug duplication of a medication you are all ready taking.
GHP also monitors each member's prescriptions, their usage, and the amount of money a member has spent for prescription drugs. Notification letters are sent to members when their expenses approach the “coverage gap”, along with suggestions for lowering the costs of prescriptions.
A Medication Therapy Management Program is in place where members with multiple disease conditions who are taking multiple medications are monitored and assessed for drug safety and cost issues related to medications.
Information on How to Request an Exception:
Telephone Call:
661-716-8800
877-697-2464
TDD/TTY 888-833-9312 for the hearing-impairedFax: 661-716-4812
Email: PartDcoverage@gemcarehealthplan.com
By Mail or Federal Express:
GEMCare Health Plan
Appeals & Grievance Department
4550 California Avenue, Suite 100
Bakersfield, CA 93309