Utilization Management

Utilization management (UM) is comprised of a myriad of edits and programs designed to help health plans change trends to better ensure safe and cost effective therapy for their members. Capitalizing on all of the potential opportunities can be complex.

We provide an integrated approach to help you get through the complexity and reach your objectives. First, our standard UM edits are designed to promote the safe, rational use of drugs. These edits include areas such as quantity limits, age edits, gender edits, duplicate therapy, and drug interactions.

Next our PA and step therapy programs continue to promote the safe and rational use of drugs, but are also designed to positively affect drug trend by driving treatment to the most cost-effective options.

Finally, implementing a strategic benefit design can also help you manage overuse and misuse through our fraud, waste, and abuse (FWA) programs, including polypharmacy, opioids and sedative utilization management. Our program has been designed to help you in reaching the greatest value from UM while providing the flexibility to choose which strategies work best for you and your members.