Pharmaceutical Management Procedures

The University of Maryland Health Partners Pharmacy and Therapeutics Committee review and approve all pharmaceutical management procedures during its meetings.  Meetings take place four times a year.  The committee members use policies and procedures to help create and manage UM Health Partners’ list of covered drugs and products.  You and your doctor may decide to use these drugs and products to help manage your health.

The decision to update the drug list is ongoing.  An update is when a drug is added or removed from the list.  The following standards help committee members make a decision on whether or not to make an update.

A drug or product:

  • treats a condition that is not treated by a drug currently listed.
  • treats a condition in a different way than a drug currently listed.
  • has been reported as safe to use.
  • is easier to use or can increase patient compliance.
  • is readily available.
  • works better than drugs or products currently listed.
  • is lower or the same price in cost to those currently listed.

UM Health Partners may also use additional pharmaceutical management procedures to manage the use of pharmaceuticals:

Generic Substitution

UM Health Partners is required by state rules to dispense generic versions of drugs and products rather than brand-name drugs and products unless a provider requests otherwise.

Prior Authorization

UM Health Partners may require providers to get approval before prescribing some drugs and products to make sure the drug or product is appropriate. Prior authorization requested by you or your provider may be reviewed by UM Health Partners’ pharmacy benefits manager for clinical appropriateness. Please be prepared to provide supporting clinical documentation to show that the member has tried and failed a formulary option. Contact CVS Health at 1-877-418-4133 for medication request review. (A CVS clinical reviewer will provide the prior authorization criteria used for evaluating the requested drugs/products upon request during the call.)

Step Therapy

UM Health Partners starts therapy with the most cost-effective and safest drugs and products. If needed, more costly or riskier therapies will be used. Contact CVS Health at 1-877-418-4133 for medication request review. (A CVS clinical reviewer will provide the step-therapy criteria used for evaluating the requested drugs/products upon request during the call.

Quantity Limits

UM Health Partners limits the amount of specific drugs and/or products covered within a certain time period based on evidence-based treatment durations. Contact CVS Health at 1-877-418-4133 for medication request review. (A CVS clinical reviewer will provide drug or product specific quantity limits upon request during the call.)

Age Limits

UM Health Partners may require prior approval of certain drugs and products based on age. (A CVS clinical reviewer will provide drug or product specific age limits upon request during the call.)

Therapeutic Interchange

UM Health Partners prohibits a pharmacist from switching a prescribed drug or product to an alternative drug or product within the same therapeutic drug class except when the pharmacist is servicing patients of a hospital, resident of a comprehensive care or extended care facility with an established procedure for therapeutic interchange.

Medication Exceptions

Non-covered drugs and products requested by you or your provider may be reviewed by UM Health Partners’ pharmacy benefits manager when the formulary does not adequately accommodate your clinical needs. Please be prepared to provide supporting clinical documentation to show that the member has tried and failed a formulary option (medical necessity). Contact CVS Health at 1-877-418-4133 for a medication exception request review.

Click here to view a complete list of drugs that you can get over-the-counter or that your provider can prescribe. Be sure to always check for updates!  Changes may occur at any time.