Drug Utilization Review

Drug Utilization Review (DUR) is a coordinated effort by physicians and pharmacists to ensure the desired outcome for a patient. DUR can be done prospectively by the pharmacist while a prescription is being processed or retrospectively by HMSA by reviewing claims data and other records for utilization patterns. There are other retrospective DUR programs available through HMSA’s pharmacy benefit manager. The goals of DUR are:

• Continuously evaluate and ensure that optimum drug therapy outcomes are achieved
• Continuously improve patient compliance
• Reduce inappropriate drug use and related hospitalizations/office visits
• Decrease adverse effects of interactions of drug use

Prospective DUR

Examples of DUR activities by pharmacists include the following:

• Therapeutic duplication – When the combined daily dose of two or more drugs will not yield added therapeutic benefit to warrant the drug cost
• Drug interactions – When the combined dosage of two or more drugs puts the patient at risk for an adverse medical effect
• Incorrect drug dosage or duration – When the dosage prescribed does not comply with accepted standards to achieve a therapeutic effect (i.e., number of days exceeds or falls short of standards)
• Overutilization – When use of a drug in the prescribed quantity or duration puts the patient at risk of an adverse medical reaction
• Drug disease contraindications – When the potential exists for the occurrence of an adverse reaction on the patient’s condition or disease
• Drug allergy interactions – When there is significant potential for an allergic reaction

HMSA’s pharmacy benefit manager’s point-of-sale system for drug claims will assist the pharmacist in the first four activities. Onsite screening of the patient at the time a prescription is filled should be done by the pharmacist to meet the last two.

Retrospective DUR

The following are retrospective DUR programs that are currently in place.

Retrospective Safety Review

HMSA’s pharmacy benefit manager’s Retrospective Safety Review reviews claims within 72 hours of processing for potential safety issues that are not addressed at the point of dispensing. The pharmacy benefit manager will then alert the prescriber and provide suggestions for improving medication therapy. The pharmacy benefit manager’s clinical pharmacists will send a letter describing the drug-drug interaction along with a complete copy of the member’s medication profile and a prescriber response form to the prescriber who triggered the edit. The pharmacy benefit manager contacts the prescriber directly as it is the prescriber who has the best understanding of the member’s health and current treatment regimens. In some cases, when the drug interaction will have an immediate onset, such as with the combination of PDE5 inhibitors/nitrates, MAOIs/amphetamines or quinolones/anti-arrhythmic agents, the pharmacy benefit manager will contact the pharmacy and/or member by phone.

Drug Savings Review

HMSA’s pharmacy benefit manager’s Drug Savings Review program reviews claims daily to identify members who might be at risk for drug-induced conditions or have opportunities for more cost-effective therapy in a series of categories, including:

• Age related
• Appropriate therapy management
• Condition management
• Duration of therapy
• Gastrointestinal
• Therapeutic duplication
• Dose optimization

The pharmacy benefit manager will recommend one of the following to the provider/prescriber by fax or phone (No changes to the prescription are made without the express permission of the prescriber).

• Different drug
• Discontinue
• Taper off
• Taper dose
• Reduce dose
• Reduce quantity
• Switch to intermittent use

Revision History