Drug Utilization Review


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.

Concurrent DUR

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).