Drug Utilization Review
KapitalRx performs drug utilization review (DUR) both after and during a patient’s course of treatment.
- Home
- Drug Utilization Review
KapitalRx RetroDUR program
Through our RetroDUR program, we review, analyze and interpret processed claims for appropriate utilization and cost-effectiveness. Our programs retrospectively review all members’ prescription claims 72 hours after they have been filled. The program alerts prescribers and pharmacies to potentially severe drug therapy issues that could result in adverse drug events. This also alerts them to members who may experience worsening medical conditions due to the absence of critical medications that are recommended for certain disease states. Alerts are communicated to the providers (prescriber and pharmacy) involved in the member’s care via fax, phone, or mail.
RetroDUR programs help our customers save money on expensive and preventable healthcare costs while improving member well-being. By managing drug therapies more effectively and intervening in a timely manner, RetroDUR serves to reduce unnecessary healthcare utilization and drive down healthcare costs. By reviewing claims, our program works to save members from moving from the lower-risk segment of a population to the high-risk segment.
In addition, the program’s Safe and Appropriate Utilization component drives prescription savings by resolving unsafe and clinically inappropriate therapy across widely utilized therapy classes. Our Gaps in Care component drives quality of care by closing gaps in medication therapy for chronic diseases.
KapitalRx Concurrent DUR program
Concurrent DUR provides timely information on potential conflicts by immediately messaging the pharmacy via the online adjudication messaging system. As a result, pharmacists can take corrective action at the time the patient is receiving the medication.
We support all combinations of real-time DUR edits, including ingredient or therapy duplication, age and sex or dosing limitations, and drug-to-drug interactions. Each edit can be set to reject claims with a hard reject (requiring an override to pay the claim) or soft reject (allowing the pharmacy to submit a standardized code to override the rejection), or to simply message the DUR information back to the pharmacy. Within each edit, the response of hard, soft, or messaging can be set individually based on the seriousness of the DUR finding (for example, the severity of a drug-to-drug interaction).
What is a drug utilization review (DUR)?
To help you better understand drug utilization review (DUR), we are excerpting information from “Drug Utilization Review” by the Academy of Managed Care Pharmacy.
Drug utilization review (DUR) is an authorized, structured, ongoing review of prescribing, dispensing and use of medication. DUR encompasses a drug review against predetermined criteria that results in changes to drug therapy when these criteria are not met.
DUR is classified in three categories:
- Prospective DUR – evaluation of drug therapy before medication is dispensed
- Concurrent DUR – ongoing monitoring of drug therapy during the course of treatment
- Retrospective DUR – review of drug therapy after the patient has received the medication
Why is DUR important?
Data and experience are at the core of drug utilization review.
Managed health care systems and pharmacy benefit management companies (PBMs) have the responsibility of managing the medication use of their patients. DUR programs play a key role in helping these organizations understand, interpret and improve the prescribing, administration and use of medications. This is often accomplished by using DUR programs to provide prescribers with feedback on their performance and prescribing behaviors as compared to pre-set criteria or treatment protocols.
The data generated by DUR also allows prescribers to compare their approach to treating certain diseases with their peers. The benchmarking generated by these comparisons is useful in stimulating prescribers to change their prescribing habits in an effort to improve care.
DUR information also assists managed health care systems and PBMs in designing educational programs that improve rational prescribing, formulary compliance and patient compliance.
What issues are commonly identified and addressed by Prospective DUR?
Prospective DUR involves evaluating a patient’s planned drug therapy before a medication is dispensed.
- Is there clinical abuse/misuse?
- Are there drug-disease contraindications (when a prescribed drug should not be used with certain diseases)?
- Should there be drug dosage modification?
- Could there be adverse or unexpected drug-drug interactions?
- Should there be drug-patient precautions?
- Are there available formulary substitutions?
- Could there be an inappropriate duration of drug treatment?
What issues are commonly identified and addressed by Concurrent DUR?
Concurrent DUR is performed during the course of treatment and involves the ongoing monitoring of drug therapy to bring about positive patient outcomes.
- Do we see any drug-disease interactions?
- Do we see any drug-drug interactions?
- Should there be drug dosage modifications?
- Do we need to re-evaluate drug-patient precautions?
- Are we seeing any over or underutilization?
- Is there therapeutic Interchange?
What issues are commonly identified and addressed by Retrospective DUR?
Retrospective DUR reviews drug therapy after the patient has received the medication.
- Was this a case for appropriate generic use?
- Was there any clinical abuse/misuse?
- Were any drug-disease contraindications noted or missed?
- Were there any adverse or unexpected drug-drug interactions?
- Was the duration of treatment appropriate?
- Was the drug dosage correct?
- Were formulary medications used whenever appropriate?
- Did we see any over or underutilization?
- Was the prescription therapeutically appropriate?