Utilization Management News

  • What is utilization management?

    Our utilization management (UM) team of physicians, nurses, and healthcare analysts support healthcare providers by promoting high quality health services that contain costs while reducing waste and harm.

    Prior authorization now required for drugs that produce white blood cells

    LifeWise now requires prior authorization before providers can order the medications Neulasta, Neupogen, and Granix for LifeWise members to purchase through a pharmacy.

    Used by chemotherapy patients, these medications are granulocyte-colony stimulating factor (GCSF) drugs, which stimulate the bone marrow to produce white blood cells. GCSF drugs present potential health risks, such as:

    • Ruptured spleen
    • Acute respiratory distress syndrome
    • Paradoxical induced thrombocytopenia (abnormally low blood platelets)
    • Bone and muscle pain

    With our new prior authorization policy for these medications, we promote evidence-based use of GCSF drugs and educate in cases when these drugs may not benefit our members. Our objectives are to improve the quality of care of our members and reduce the use of potentially unnecessary toxic drugs.

    This prior authorization policy applies when providers order these medications for a LifeWise member to get through a pharmacy. (Current members who have a claim prior to Aug. 30, 2014, will not need a pre-service review to continue filling the prescription.)

    If providers administer a GCSF drug in the office or have the patient administer it at home, a pre-service review is recommended to determine if it meets medical necessity criteria and if the member’s plan covers it.

    In cases when a GCSF drug is deemed a medical necessity, LifeWise recommends members to discuss with their providers Granix over Neulasta or Neupogen, due to its ability to be used in a vast majority of cases where GCSF drug therapy is prescribed as well as its cost-effectiveness as compared to the other GCSF medications.

    Read our GCSF drug policy.

    Source: (Abraham I, Tharmarajah S, MacDonald K.) Clinical Safety of Recombinant Human Granulocyte Colony-Stimulating Factors. Expert Opin Drug Saf 2013;12(2):235-246.

    Using Choosing Wisely® to inform LifeWise Utilization Management policies

    Choosing Wisely is a physician-sponsored campaign, led by the American Board of Internal Medicine (ABIM) Foundation, which seeks to create stronger relationships between providers and patients. Founded in 2012, the campaign offers information about tests, procedures, and services so that patients and their providers can make wise decisions about individual care. Since that time, the campaign has published more than 135 evidence-supported recommendations that come from medical specialty societies.

    Choosing Wisely’s goal is to promote conversations between providers and their patients so they can choose care that is:

    • Most appropriate
    • Supported by evidence
    • Free from harm
    • Truly necessary

    LifeWise aims to give our members access to effective, quality care. That is why we consider Choosing Wisely’s recommendations when developing our policies.

    Choosing Wisely’s recommendation on vitamin D testing

    Vitamin D deficiency is common in many populations, particularly during winter months for those who live at higher latitudes and for those with limited sun exposure.

    Albeit vitamin D deficiency is known to be common in these instances, Choosing Wisely identified a tendency of unnecessary vitamin D testing. For most patients that are otherwise healthy, the use of over-the-counter vitamin D supplements and increased sun exposure may be sufficient to treat vitamin D deficiency without the need for testing.

    Choosing Wisely recommends that higher risk patients — such as those diagnosed with osteoporosis, chronic kidney disease, malabsorption, some infections, or obesity — should be tested for vitamin D deficiency. Testing for such patients is important because the results can be used to institute more aggressive therapy.

    Choosing Wisely’s recommendation on bone density testing

    This test is used to identify the likelihood of breaking a bone, determining a diagnosis of osteoporosis, or monitoring osteoporosis. Age tends to be a strong indicator for the increased likelihood of weak bones and the need for bone density testing. As a result, Choosing Wisely offers specific recommendation for this testing based on age and gender:

    • For women, 65 and older, a bone density test is recommended. Men, 70 and older, should also consider speaking with their doctors about this test.
    • For women and men below this age range, a test should only be consider if they have risk factors such as a fracture from minor trauma, rheumatoid arthritis, a parent who had a hip fracture, or a history of smoking, heavy drinking, or long-term drug use. (Under any of these circumstances whether a follow-up bone density test is needed depends on the results of the initial scan.)
    Women Men
    Under 65  65 and older  Under 70  70 and older 
    Should be considered if at a high risk Recommended Should be considered if at a high risk Consider speaking to doctor

    Choosing Wisely, as does LifeWise, recommend that women and men of any age take steps to build or improve bone strength by performing weight-bearing exercises, taking supplemental calcium and vitamin C, and by speaking with a doctor about minimizing medications that may be affecting bone mass.

    Learn more about Choosing Wisely and its recommendations.

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