Utilization Management for Medications for Addiction Treatment Toolkit
This toolkit is intended to give prescribers a broad overview of medication utilization management techniques and describe ways that prescribers can facilitate patient access to needed medications. It focuses on prescribed medications that are filled by retail pharmacies; it does not cover the processes for methadone or specialty pharmacy products, such as injectable or implantable medications, all of which are commonly covered by a patient’s medical benefit rather than their pharmacy benefit.
Utilization management (UM) is a set of techniques used by payers on behalf of purchasers of healthcare benefits to manage healthcare costs, ensure services align with payers’ medical necessity criteria, and reduce or eliminate care that is wasteful, inefficient, or unnecessary. These techniques include setting broad quality and payment standards for the covered population and influencing patient care decision-making through case-by-case assessment of the appropriateness of care prior to its provision. Ideally, UM sustains high quality care by ensuring that services follow generally accepted standards of care as defined by national medical specialty society-developed guidelines. For prescribers, however, UM can be frustrating and, if not navigated correctly, lead to delays in patient treatment.
Medications for addiction treatment are subject to several types of UM, including prior authorization, medical necessity review, formulary restrictions, quantity and dose limits, and step therapy. Although unpopular among prescribers, payers use UM techniques to direct prescribers to less expensive branded or generic medications, to help ensure adherence to standards of care, to identify dangerous medication interactions that prescribers may miss, particularly in cases where patients are receiving medications from multiple providers, and control costs. Payers are strictly regulated and must conform to a wide range of constraining state and federal law and regulation.