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

How are 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How are pharmacy UM programs created: FDA labeling, compendia, guidelines, literature, unpublished data, data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