Prescription Drug Information

Quality Assurance Policies & Procedures

Quality Assurance Policies & Procedures

(Medication Therapy Management (MTM) Program & Utilization Management)

We have established measures and systems to conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. The programs include real-time and historic review of prescriptions claims to reduce medications errors and adverse drug interactions. These reviews are especially important for members who have more than one doctor who prescribe their medications, use more than one drug, or have more than one pharmacy.

Blue Shield of California Promise Health Plan conducts drug utilization reviews when your pharmacy fills your prescription at the point-of-sale. The claim may be electronically reviewed for the following:

  • Screen for duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Age-related contraindications
  • Gender-related contraindications
  • Drug-Drug interactions
  • Incorrect drug dosage
  • Incorrect duration of therapy
  • Clinical abuse or misuse

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.



Medication Therapy Management (MTM) Program | Utilization Management




Material ID: H0148_19_028_WEB
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