High Risk Medications Program
The Centers for Medicare and Medicaid Services (CMS) developed performance and quality measures to help Medicare beneficiaries make informed decisions regarding health and prescription drug plans. As part of this effort, CMS adopted measures for High Risk Medication (HRM) endorsed by the Pharmacy Quality Alliance (PQA) and the National Quality Forum (NQF). The HRM was developed using existing HEDIS measurement “Drugs to be avoided in the elderly”. The HRM rate analyzes the percentage of Medicare Part D beneficiaries 65 years or older who have received prescriptions for drugs with a high risk of serious side effects in the elderly.
AGS Beers Criteria 2019 (PDF)
Information on this page is current as of December 10, 2021.
Medication Therapy Management
IEHP offers Medication Therapy Management (MTM) to qualified Members. MTM is a term to describe a broad range of services offered by Pharmacists on our health care team.
The IEHP Clinical Pharmacy Team reviews the Members’ medicines, making sure they’re taking the right ones for their health conditions. If you are a Provider for IEHP Members who qualify for the MTM Program, you can let them know to look out for a letter from us. They will be enrolled automatically—unless they opt-out. MTM is offered to Members at no additional cost.
IEHP's MTM services include these core elements:
- Medication therapy reviews
- Medication education
- Disease management
A team of Pharmacists and Doctors developed these MTM services to help provide better prescription drug coverage for our Members. For example, MTM also helps identify possible medication errors.
Medicare MTM Program
This is a free program under Medicare Part D for IEHP DualChoice Members who have multiple medical conditions, take many prescription drugs, and have high drug costs to assist with better medication management and overall health.
IEHP DualChoice Members’ enrollment includes a yearly comprehensive medication review (CMR) and regular targeted medication review (TMR) services throughout the year. MTM services include:
|Comprehensive Medication Review (CMR)||An IEHP Clinical Pharmacist will provide an annual comprehensive review of the IEHP DualChoice Member’s medications over the phone. The Pharmacist will review IEHP DualChoice Member’s medications and make clinical recommendations to IEHP DualChoice Members and Providers.|
|Targeted Medication Review (TMR)||The IEHP Clinical Pharmacy Team will also offer TMRs through the year by reviewing issues with the participating IEHP DualChoice Member’s medicines. The team will perform TMRs for all enrolled beneficiaries every three months. The beneficiary may get TMR recommendations by mail and their Primary Care Provider may receive recommendations by fax—if the IEHP Clinical Pharmacy Team deems it necessary.|
For more information, IEHP DualChoice Members eligible for CMR or TMR services can call 1-877-273-IEHP (4347), 8am-5pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347. Click here for a blank personal medication list.
Medicare MTM Program services may have limited eligibility criteria. They are available for the following conditions:
1. The IEHP DualChoice Member has a minimum of three (3) disease states:
- Bone Disease-Arthritis-Osteoporosis
- Bone Disease-Arthritis-Rheumatoid Arthritis
- Chronic Heart Failure (CHF)
- End-Stage Renal Disease (ESRD)
- Mental Health Chronic/ Disabling Mental Health Conditions
- Respiratory Disease – Asthma
- Respiratory Disease – Chronic Obstructive Pulmonary Disease (COPD)
2. The IEHP DualChoice Member is prescribed a minimum of five (5) different medications to treat those disease states:
- Angiotensin II Receptor Blockers (ARBs)
- Beta Blockers
- Calcium Channel Blockers
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
- Oral Hypoglycemics
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Tumor Necrosis Factors (TNFs)
- Inhaled Corticosteroids
- Cardiac Glycoside
- Colony Stimulating Factors
- Glucagon-Like Peptide-1
- Neprilysin Inhibitor
- Phosphate Binders
- Vitamin D Analogs
3. Drug costs of $1,174 (one-fourth of $4,696) for the previous three months are likely to be incurred.
For answers to frequently asked questions, please download the FAQ document below:
For details, contact the IEHP Pharmaceutical Services Department at (909) 890-2049, Monday-Friday, 8am-5pm.
IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
Information on this page is current as of October 2022.
Pharmacy Pain Management (PPM)
The goal of the Pharmacy Pain Management (PPM) program is to proactively manage members on multiple opioid therapies to prevent overutilization, identify unsafe and inappropriate opioid use, and address potential fraud, waste, and abuse.
Identified members at risk of opioid overutilization will be evaluation through our Pharmacy Pain Management Program (PPM). A clinical team will be reviewing member therapy and reaching out to the primary provider to discuss the existence of multiple prescribing providers, member's total opioid utilization, appropriate level of opioid use for the member, and considerations for implementation of a member-level claim edit.
After review and consultation with the prescribing provider, if the member's therapy is determined to be appropriate and medically necessary, no further action will be taken. Results of consultation with provider and findings will be documented.
After review and consultation with the prescribing provider, if the member's therapy is determined to be inappropriate, and the provider recommends member-level point of sale claim edit, the member will be mailed a notification letter-that entrails the provider's recommendation. Medicare members will receive the notice 30 days in advance of the point of sale claim edit implementation.
Member may also be referred for evaluation and monitoring by a pain management specialist.
Resources and Tools:
For convenience, the URL link to the State of California Department of Justice's Controlled Substance Utilization Review and Evaluation Systems (CURES), California Prescription Drug Monitoring Program (PDMP) site. By clicking on this link, you will be leaving the IEHP website. http://oag.ca.gov/cures-pdmp
Information on this page is current as of January 1, 2022
Rx PA Drug Treatment Criteria
Prescription Drug Prior Authorization (Rx PA) Drug Treatment Criteria
On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 (EO-N-01-19) for achieving cost-savings for drug purchases made by the state. A key component of EO N-01-19 requires the Department of Health Care Services (DHCS) transition all Medi-Cal pharmacy services from managed care (MC) to fee for service (FFS).
- Click here to go to the “DHCS Medi-Cal Rx” page on IEHP website
- Click here to go to “Medi-Cal Rx: Transition” page on DHCS website
Updated April 7, 2021, this document describes DHCS’ multi-faceted pharmacy transition policy, inclusive of “grandfathering” previously approved PAs from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, to help support the Medi-Cal Rx transition. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx.
- Click here to view “Medi-Cal Rx Pharmacy Transition Policy” from DHCS website
Drug Prior Authorization Criteria
Drug Class Prior Authorization Criteria
- Adult Enteral Nutritional Supplement (PDF)
- Antineoplastic Agents (PDF)
- Erythorpoieses-Stimulating Agents (PDF)
- Growth Hormones (PDF)
- Hepatitis C (PDF)
- Hereditary Angioedema (PDF)
- Immuno Globulins (PDF)
- Nutritional Supplement Infant Formula (PDF)
- Opioid Analgesics (PDF)
- Pediatric Enteral Nutritional Supplement (PDF)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitor (PDF)
- Testosterone Hormone Replacement (PDF)
- Therapeutic Agents in Rheumatic And Inflammatory Diseases (PDF)
- Discharge Policy (PDF)
- Drug Trial and Failure (PDF)
- High Daily Morphine Milligram Equivalent (PDF)
- IEHP Drug Prior Authorization Policy (PDF)
- Intradialytic Parenteral Nutrition (IDPN) Policy (PDF)
- Non-Formulary Drug (PDF)
- Non-Sterile Compounded Medication (PDF)
- Off-Label Indication Policy (PDF)
- Pharmacy Drug Management Program for Pain (PDF)
- Quantity Limit Policy (PDF)
Information on this page is current as of January 1, 2022.