PBM-Plan Management: Drug Utilization Review

Drug Utilization Review (DUR)

The Universal Rx DUR is a management process that preserves the clinical integrity of the plan design while maximizing cost-effectiveness.

A Universal Rx managed prescription benefit plan will reduce annual health care costs by 18-21%

Drug Utilization Review (DUR) assures members receive appropriate drug therapy based on current medical guidelines. The retail or mail order pharmacy will access a member’s file via online systems. Prior to dispensing a prescription, DUR edits are applied against the prescription and the patient’s profile, checking for duplicate drug therapy, over-utilization or under-utilization patterns, duration of therapy and proper dosage information. This system catches potentially unsafe and inappropriate drug use prior to dispensing the prescription. This improves the quality of members’ health while lowering overall pharmacy costs.

Our Drug Utilization Review focuses on the three stages of the prescription process:

Prospective: focuses on what determines the physician’s prescription pattern BEFORE communication to the pharmacist
Concurrent: focuses on providing the pharmacist the necessary information, through a series of real-time edits and analyses, DURING the prescription fulfillment process
Retrospective: focuses on the evaluation of data AFTER prescription claims have been processed to improve prescribing, dispensing, and usage patterns in order to maximize the value of the plan

Detailed Drug Utilization Review Information

Prospective Drug Utilization Review

Universal Rx provides custom support to clients for Prospective Drug Utilization Review projects. We have supported client application of historic data to modify and enhance future physician prescribing practices. For example, physician-prescribing habits have been reviewed to identify practitioners that may need more information about quality and cost effective drug therapy options, and/or to supply those practitioners with information about therapeutic class reviews, treatment guidelines, and treatment alternatives.

Concurrent Drug Utilization Review

Universal Rx’s system utilizes online, real-time Concurrent Drug Utilization Review procedures to prevent drug duplication and to identify drug interactions. We use NCPDP’s DUR modules to check for drug interactions. We also have proprietary algorithms established to detect duplicate therapy. In addition, the Medi-Span™ DUR Criteria are applied in the concurrent utilization review activity. Universal Rx utilizes the following three (3) Medi-Span Drug Therapy Monitoring System™ (DTMS) Drug Utilization Review modules:

Drug Therapy Monitoring System™

Allows screening for drug-drug interactions, prior adverse reactions to medications (including drug-allergy interactions), food-drug interactions and drug-alcohol interactions. The system can be customized to meet the needs and clinical input capacity of a particular program.

Drug-Disease Monitoring System™

Screens medications to detect contraindications for use based on a patient’s disease state or medical condition, including diseases, age (pediatric or geriatric), pregnancy and lactation.

Dose-Chek™

Allows screening for daily dosages of most commonly used medications that exceed or fall below established daily dose ranges.

Our system incorporates both hard and soft edits that are preformed at the point of service for retail and mail order prescriptions. Based on the client’s preferences, Universal Rx can incorporate drug-drug interaction edits that can result in claim rejection and cause the pharmacy to receive a customized message. These edits can be customized over time for the client and modified over time within a day’s notice. A series of edits / rejects are in place to guard against duplicate claims payments.

Retrospective Drug Utilization Review

Universal Rx provides client support for Retrospective Drug Utilization Review. The activities include:

Support for NCQA management and custom utilization review projects.
Plan level reporting that communicates issues associated with drug cost and utilization in high visibility therapeutic classes including change in cost per member per year and utilization per 1,000 members from period to period and contrasts it with national managed care benchmarks.
Custom reporting options that support evaluation of practitioner prescribing habits within a practice specialty and within particular drug classes (historically, these reports provide data concerning generic substitution, formulary selection, and drug cost per prescription; however, clients may customize these reports to meet its needs and specifications).
Individual Patient Drug Regimen Review with individuals identified from exception reports that are produced quarterly. Depending on Client needs and desires, a patient drug use profile that identifies relevant drug use issues can be prepared and distributed to physicians involved in the care of the patient.

It should be noted that our DUR program integrates both drug card and mail order purchases should our Clients ever choose to implement such a program. Average savings per prescription resulting from the interventions are calculated for all reports based on analysis that examines both pre-reporting and post-reporting as well as intervention cost comparisons.

Finally, our DUR program profiles physicians’ prescribing practices and provides educational material to inform physicians of problematic prescribing patterns.

Physician Level Reporting

This reporting describes physician product selection for all drugs and for selected drug classes contrasted with product selection by peers within a practice specialty. This has particular value when the plan has a direct relationship with physicians.

In plans with direct physician relationships, it is recommended that physician reporting be produced and communicated at least quarterly throughout the year. Election of this program provides product selection data for an individual physician contrasted with peers (within practice specialty if data is available) in a global report and in selected drug class specific reports. This report can be accompanied by plan specific clinical guidelines and drug cost comparison information with each report.

Comparison of physician drug product selection activity from pre-report and post-report periods, indicates greater prescribing of generic alternatives, formulary drugs, and improved attention to clinical guidelines. While not quantified, physician attention to product selection issues provides reductions in drug cost due to selection of lower cost alternatives within specific drug classes.

The Universal Rx Drug Utilization Review Program is provided at no additional cost to our clients. All the services just described are built into our base program. This includes the provision of reporting as well.

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Prescription Benefit Management
Prescription Drug Card Program — On-Going Plan Management

Drug Utilization Review (DUR)