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Overview and Objectives

At THCI’s Mini-Rotation, this breakout group exercise was preceded by a presentation on Utilization Management by a Medical Director at a local health plan. The presentation included following elements:

  • Definition and characteristics of utilization management, as generally practiced by health plans and purchasers.
  • Guidelines and processes applied by health plans when reviewing appropriateness of specified clinical care decisions, services, procedures or therapeutic agents and health benefits coverage decisions for such treatment.
  • Steps required of physicians when seeking such a determination.

Examples of review decisions discussed in the presentation included a request for the antidepressant Pristiq in the context of Step Therapy protocols, and coverage of high-cost drugs like Esbriet (pirfenidone). After the presentation, the residents were divided into three groups of 8-9 participants to review and discuss utilization management case scenarios. One health plan Medical Director facilitated each small group discussion.


By the end of this exercise, all participants should be able to:

  • Describe and characterize a health plan’s utilization management and review process for determining patient care and coverage decisions involving pharmaceuticals and procedures not routinely covered by the patient’s health benefits plan.

The case scenarios used in the THCI Mini-Rotation were based on actual reviews and are not available for distribution. Educators wishing to offer a similar learning exercise should consider collaborating with a health plan in their geographic area, both for this exercise and for the course as a whole.