PHARMACY / MEDICAL UTILIZATION MANAGEMENT GUIDELINE
Defines medical-necessity criteria for continuing coverage of maintenance medications when a member is new to the plan or when utilization management restrictions change for current members, distinguishing drugs with and without preferred generic/biosimilar alternatives and addressing manufacturer samples/coupons.
Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information.
Added coverage criteria for continuation of a maintenance medication for new to plan members for a drug that does have a preferred generic or biosimilar alternative (12/01/24).
Added coverage criteria for continuation of a maintenance medication for current plan members for a drug that does have a preferred generic or biosimilar alternative (12/01/24).
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.