Drug Utilization Review

CenCal Health Drug Utilization Review (DUR) Program

CenCal Health’s Drug Utilization Review program is an authorized, structured, ongoing review of healthcare provider prescribing, pharmacist dispensing, and patient use of medication.  The program includes a comprehensive review of patients’ prescription and medication data to ensure appropriate medication decision making and positive patient outcomes.  The CenCal Health DUR program is classified into two categories:

• Retrospective–Review of therapy after the patient has received medication
• Educational – Outreach program to educate practitioners on common therapy problems

These reviews play a key role in helping managed health care systems understand, interpret, and improve the prescribing, administration, and use of medications.

Retrospective DUR Program Overview:

A retrospective DUR is reviewed after the patient has received the medication.  The review may detect patterns in prescribing, dispensing, or administering drugs to prevent recurrence of inappropriate use or abuse, and serves as a means for target interventions.  In retrospective DUR, examination of claims and other records determine whether the drug therapy met approved criteria, and aids prescribers in improving care for their patients, individually and within groups of patients, such as those with diabetes, asthma, or high blood pressure.

Issues Commonly Addressed by Retrospective DUR:

• Therapeutic appropriateness
• Over and underutilization
• Therapeutic duplication
• Drug-disease contraindications
• Drug-drug interactions
• Incorrect drug dosage
• Clinical abuse/misuse

Example of a Retrospective DUR:

• An analysis of member prescription utilization may identify a group of patients whose therapy does not meet approved guidelines. Upon retrospective review CenCal Health may identify a group of patients with asthma who, according to their medical and pharmacy history, should be using orally inhaled steroids. Using this information, CenCal Health can then encourage physicians to prescribe the indicated drug.

DUR Educational Program Overview:

An educational outreach program to educate practitioners on common drug therapy problems with the aim of improving prescribing and dispensing practices. These educational efforts are in collaboration with the State DUR board’s educational program as shared with CenCal Health.