Question

Which of these statements is true about the drug utilization management (UM) rules?

Neither the member nor the prescriber can ask the plan for an exception if they believe that one of the coverage rules should be waived.
Prior authorization, quantity limit, and step therapy are some examples of the UM rules.
UM rules do not need to be disclosed to the consumer.

Answer 1

Drug utilization management rules include prior authorization, quantity limit, and step therapy, and contrary to the misinformation, both members and prescribers can request exceptions to these rules and they must be disclosed to consumers.

Step-by-step explanation:

The statement 'Prior authorization, quantity limit, and step therapy are some examples of the UM rules' is correct regarding drug utilization management (UM) rules. The other statements provided are not accurate. In practice, both members and prescribers have the right to request an exception if they believe that a coverage rule should be waived, which is a standard feature in many health plans that include UM rules. Furthermore, UM rules typically need to be disclosed to the consumer to ensure transparency and understanding of their coverage.