800-958-1129 (TTY: 711)
We are open M-F 8:00 a.m. – 8:00 p.m. PT. Between 10/1 and 3/31, we are open 7 days a week, except for the major year-end holidays. You can enroll beginning 10/15/2025.
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Part D Quality
Assurance
Elite Health Plan applies several Quality Assurance and Utilization Management Initiatives that are designed to improve quality, prevent over- and underutilization and reduce costs. These programs include but are not limited to Medication Therapy Management, Concurrent Drug Utilization Review, and Retrospective Drug Utilization. These programs are available to promote safe utilization of medications and at no extra cost to Part D Members.
Concurrent Drug Review
Elite Health Plan has policies and procedures designed to ensure that a review of the prescribed drugs is performed at the point of sale or distribution before a prescription is dispensed to a member. Elite Health Plan, through its Pharmacy Benefits Manager (PBM), promotes appropriate dispensing and use of drugs to ensure high quality of care and cost-effective therapy. The program also periodically reviews claims data retrospectively.
On-line reviews or edits include but are not limited to:
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Drug-Drug Interactions
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Duplicate Therapy
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Duplicate Drug Class
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Drug Age/Gender Edit
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Over/Under utilization
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Incorrect Drug Dosage/Duration of Therapy
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Drug-to-Disease Contraindication
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Drug/Allergy Edits
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Abuse or Misuse
This program is not considered a benefit.
Retrospective Drug Utilization
Elite Health Plan utilizes a retrospective Drug Utilization Review (DUR). The DUR is designed to provide ongoing periodic examination of claims data and other records through a computerized drug claims and information retrieval system. The system being used to identify patterns of inappropriate or medically unnecessary drug use associated with specific drugs or groups of drugs.
These DUR reviews include but are not limited to the following:
Alerts to prescribers on drug related therapy problems.
Brand and Generic drug utilization with provision of alternative ways to improve costs.
Physician utilization reports that identify over/under utilization, patterns of prescribing, poly-pharmacy patients.
This program is not considered a benefit.
These programs also work in conjunction with other clinical management tools to encourage the safe, appropriate, and cost-effective use of Medicare Part D Prescription Drugs. More information about these three programs is available within the Formulary Booklet.
Prior authorization (PA)
A PA requirement means the member, or their doctor must get approval before your medication is covered at your pharmacy.
Step therapy (ST)
A ST requirement means you must first try one drug to treat a medical condition before another drug will be covered for that same condition.
Quantity limits (QL)
A Quantity Limit requirement limits the amount of a drug that will be covered with prior approval.
Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Elite Health Plan Medicare Part D plan.
Quality Assurance
Elite Health Plan ensures the safety and health of its members through the establishment of effective Quality Assurance measures and systems. We do this to reduce medication errors, adverse drug reactions, and improve medication utilization. These measures include making sure that providers comply with pharmacy practice standards, drug utilization review, internal medication error identification systems, medical therapy management programs, and pharmacy and therapeutics committees. Included in the Quality Assurance process, selected cases are discussed with the objective of improving care.
A major goal of Elite Health Plan is to ensure that our beneficiaries receive safe, high-quality, cost-effective medication therapy. To achieve this goal, Elite Health Plan works with a claims processor to put certain edits in place to promote appropriate medication therapy. These edits help prevent patients from taking drugs that may have harmful interactions, prevent patients from receiving higher than recommended doses of a medication, notify patients of lower cost alternative medications, and provide other safety and efficacy safeguards.
Elite Health Plan will also provide appropriate education and may coordinate with prescribers and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse and inappropriate or medically unnecessary care.