Drug Utilization Review

There are three types of drug utilization review programs:

  • concurrent,
  • retrospective, and
  • prospective.

Concurrent DUR Program

Concurrent DUR uses innovative information technology to proactively warn the dispensing pharmacist of potential drug problems.
The concurrent DUR system operates in an on-line, real-time environment. The Clinical Decision Support SystemSM (CDSS) checks all incoming prescriptions to prevent the patient from experiencing inappropriate drug prescribing or consumption, medical conflicts or potentially dangerous interactions.

Concurrent DUR enables mail service managed care and retail network pharmacists to avert many therapeutic problems since changes in dosing, duration, or product selection are made prior to dispensing.

Retrospective DUR Program

Highmark's enhanced retrospective DUR program identifies patterns that do not meet the established clinical and plan guidelines. This program maximizes the clinical and financial impact on prescription drug benefits, by evaluating the entire patient population for inappropriate utilization.
Retrospective DUR identifies prescribing, dispensing, and consumption patterns which are clinically and therapeutically inappropriate and do not meet the established clinical practice guidelines.

Clinical alerts and their associated patient profiles are aggregated by prescriber for the initiation of a written intervention, specifically designed to improve therapeutic outcomes and the quality of patient care. Prescribers whose patients' profiles generate clinical alerts are sent a single, enhanced intervention communication containing:

  • A cover letter outlining the goals of the program and a list of all the patients involved.
  • A patient-specific communication outlining theclinical issues involved and recommended courses of action for each patient, with supporting clinical references and citations.
  • A fully integrated patient drug history profile for all alert drugs and other medications.
  • A response form providing the prescriber with a vehicle to indicate his or her concurrence or disagreement with the clinical issues and recommendations for resolution.

Prospective DUR Program

Highmark's profiling process begins with the development of a comprehensive set of clinical rules and prescribing guidelines designed for effective provider network management. Highmark has developed specific profiling rules to manage utilization in the following therapeutic areas:

  • Antibiotic prescribing
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) prescribing
  • Antihypertensive prescribing
  • Generic drug prescribing

Our profiling rules extend beyond the industry's standard managed care variables such as average prescription cost per member per month (PMPM), generic substitution index, and formulary compliance index. We include extensive sets of utilization measurements, which target key therapeutic areas. The resulting clinical rules form the basis for measuring physician prescribing.

Last updated on 10/31/2017


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