Quality Assurance Policies and Procedures

A Part D plan must have established quality assurance measures and systems to reduce medication errors and adverse drug interactions and improve medication use.

Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members.

Drug Utilization Review

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records.

Medication Therapy Management Program

We offer a medication therapy management program at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. This program was developed by a team of pharmacists and doctors. We use our disease state management programs along with a pharmacy review program to help us provide better coverage for our members. For example, this program helps us make sure that our members are using safe and appropriate drugs to treat their medical conditions and hopefully improve their overall health and well being.

A member must meet all three of the following criteria to be eligible for Gateway Health Plan Medicare Assured^SM's MTM Program:

1. Have 3 or more of the following chronic disease states: AIDS/HIV, Asthma, Chronic Pain - osteoarthritis or rheumatoid arthritis, COPD, Diabetes, Schizophrenia, Bipolar Disorder, Depression, Dyslipidemia, Heart Failure, Hypertension, Multiple Sclerosis, High risk pregnancy
2. Have 6 or more prescriptions filled for Part D covered drugs
3. Have the cost of Part D drugs on track to exceed a minimum dollar amount established by CMS.

If you are identified as being eligible for the MTM program you will be contacted and asked whether or not you want to be part of the program. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you do not need to pay anything extra to participate. If you agree to be a part of the program you will be followed by the appropriate program for your disease state. You may be provided with educational materials and opportunities to discuss your medications with a pharmacist. Gateway Health Plan Medicare Assured^SM may also consult with your doctor to make sure you are on the best drugs and doses to treat your condition. You can contact Gateway Health Plan^® Member Services for additional information.

If you have any questions concerning Gateway’s MTM Program, please contact Member Services at 1-800-685-5209 8:00 a.m. - 8:00 p.m., 7 days a week. TTY users should call 1-800-654-5988