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.
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:
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.
GCSF drug policy.
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:
LifeWise aims to give our members access to effective, quality care. That is why we consider Choosing Wisely’s recommendations when developing our policies.
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.
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:
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.
Search Utilization Management Policies.