Lecture 7. Pharmacy Utilization Management, Parmar

Utilization management

set of services offered by managed care organization to encourage to appropriate use of pharmaceuticals by providing effective controls on drug benefit

Benefits of UM

improved quality of care, reduced drug spending, promote patient compliance

Types of drugs selected in pharmacy UM programs

high potential for inappropriate drugs (weight loss drugs, narcotics), lots of off-label uses, specialty drugs, high-cost drugs, unsafe drugs with BBWs

How are pharmacy UM programs created

FDA labeling, compendia, guidelines, literature, unpublished data, data

UM Criteria approval process

reviewed by a consultant (physician) and P&T

Does every single drug need a UM

no

Before implementing UM edit

we run numbers to see how many members and physicians will be impacted and mail letters

Quartly, UM edits are evaluated for

how many rejected claims and how many requests

UM Tools

Prior authorization, step therapy, drug dispensing limit, dose optimization, drug utilization review, specialty pharmaceuticals

Prior authorization

drug reject at the point of service

Drugs affected by Prior Auth

ADHD meds, weight loss meds, biologics, testosterone, isotretinoin

Step Therapy

drug rejects at point of service if trial of a first-line agent is not captured in the system (for example, pt trying to get a complex diabetes med before trying metformin)

Examples of Step Therapy

generic drugs before brand drugs, allopurinol before ER, metformin before newer diabetes meds

Drug Dispensing Limitations

drug reject at the point of sale if medication claims is over the recommended maximum daily dose OR use in an age that is not FDA approved

Dose Optimization

point of service management of reviewing drug therapy for multiple daily doses of a low-strength medication where a higher strength once-daily dose may be available and equally effective

Benefits of Dose Optimization

improve member compliance & manages costs

Medications under Dose Optimization Protocols

ADHD, statins, sleep agents, pain meds

Drug Utilization Review (DUR)

can be prospective and retrospective

DUR is mandated by

JCAHO and NCQA

Medical Coverage

administered by HCP

Pharmacy coverage

administered by pt or caregiver