Which statement describes the purpose of Utilization Management Rules in prescription drug plans?

• A. They determine network provider eligibility.
• B. They govern how medications and services are reviewed for coverage, including steps like step therapy and prior authorization.
• C. They set the annual premium amount.
• D. They define enrollment period options.

Answer: (B)

Utilization Management Rules in prescription drug plans govern how medications and services are reviewed for coverage, including steps like step therapy and prior authorization. They determine whether a drug is approved for coverage, under what conditions, and what evidence of medical necessity is required. Step therapy means a preferred, typically lower-cost therapy must be tried before the requested drug is approved. Prior authorization requires the clinician to justify medical necessity before coverage is granted. These mechanisms help ensure safe, effective, and cost-conscious use of medications within the plan.

Other aspects focus on who can bill from a network (provider eligibility), how much the plan charges for premiums, or when enrollment is allowed, but these do not decide coverage of specific drugs or services.