Use Management Requirements for Atripla

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Medical Utilization Management Program Updates Effective April 8, 2018

We would like to share an overview with you regarding our standard medical Utilization Management (UM) Program updates effective for requests beginning April 8, 2018. These updates will be posted to our website, by March 8, 2018, and will include the introduction of a new musculoskeletal preauthorization program. Details regarding this new program will be shared with the appropriate practitioner specialties in the coming weeks.

The UM Program gives the health plan and its health care provider partners the opportunity to monitor medical episodes of care to prevent unnecessary treatment and duplication of services, while it also helps to uncover opportunities to maximize greater health outcomes. We thank our participating providers for collaborating with us to ensure that our members receive the right care at the right time.

Preauthorization is required for all services listed on our preauthorization list, regardless of the place of service (i.e., office, inpatient or outpatient setting). Please keep in mind that failure to follow UM policies and procedures, including failure to obtain preauthorization, failure to comply with your provider agreement or our member contract requirements may result in claim denial or reduction in payment.

If you have any questions regarding the following updates to our UM Program, please contact Customer Care at 1-866-265-5983.

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Utilization Management