Drug Utilization Review

Clinical programs for health, safety, and cost containment

Introduction This information is used to aid in the

detection of drug-related problems (e.g.,
Medco Health’s Drug Utilization Review drug dose, drug allergy, drug duplication,
(DUR) programs are a series of clinical drug-drug interactions, and drug-disease.
programs that systematically evaluate When potential problems are identified,
prescriptions for health, safety and cost- information and decision support are
containment issues, including over-use, provided to physicians and pharmacists
misuse and under-use of prescription using a variety of communication channels.
medications. Utilizing pre-defined,
evidence-based clinical rules and Drug Utilization Review with
audience-specific messages, Medco Pharmacists
Health’s DUR programs notify
pharmacists and physicians of important Medco Health’s Drug Utilization Review
therapeutic issues regarding the program with Pharmacists provides
appropriate use of prescription prescription-specific and pharmacy-specific
medication. By alerting providers to information and decision- making support.
these issues, the DUR programs: This information is communicated at the
• Help safeguard patients from point-of-sale (POS) via Concurrent Drug
potential harm resulting from over- Utilization Review services.
use, under-use and misuse of Concurrent Drug Utilization Review
prescription drugs. (Concurrent DUR)
• Improve quality of care for members
while lowering costs for clients Concurrent DUR involves on-line, real-time
screening of claims at the point of
• Promote awareness of clinical dispensing. Every prescription is screened
guidelines and plan policies for all prior to dispensing for a broad range of
constituents safety and economic considerations. The
pharmacist is alerted to every prescription
The rules are designed to draw the for which a relevant issue is identified.
attention of the pharmacists and Medco Health seeks to continuously
physicians to specific prescriptions improve the performance and accuracy of
based on the following elements: the Concurrent DUR program by
• prescription information maintaining and improving the
comprehensive set of medically sound
• available prescription history,
clinical rules that drive system alerts.
• demographic information,
Medco Health uses a single set of
• self-reported health information
integrated clinical rules that are applied
• available medical and diagnosis data. concurrently at both Home Delivery
pharmacies and participating retail
 Drug Utilization Review
Clinical programs for health, safety, and cost containment

pharmacies. Medco Health’s Concurrent Concurrent DUR - Administration

DUR rule set is based on the industry
standard created and maintained by First A prescription that is in violation of one or
Data Bank. However, the rule set has more rules triggers either an alert to the
been expanded and enhanced. dispensing pharmacist with a warning
Specifically, Medco Health has filled message (a soft alert), or rejects the claim
gaps by developing proprietary for adjudication (a hard alert). "Soft alerts"
Concurrent DUR rules using prescribing defer alert resolution to the professional
guidelines, peer-reviewed medical judgement of the pharmacist. When a
literature and manufacturer information. "hard alert" is triggered, the system alerts
the dispensing pharmacist to the potential
The Seniors rules within Medco Health’s problems and rejects the claim for
Concurrent DUR Program are the adjudication. For select categories of “hard
foundation of our Partners for Healthy alerts”, the system allows the dispensing
Aging program. The rules identify drugs pharmacist to override the alert by
best avoided in the elderly and dosing documenting resolution of the issue.
issues specific to the elderly. There is a
special emphasis on conditions such as As a matter of policy, Medco Health
insomnia, depression/anxiety and administers all Concurrent DUR alerts as
diabetes, which are common among the “hard” alerts in the Home Delivery
elderly. Pharmacies. Standard Concurrent DUR
alerts at retail are administered as warning
Concurrent DUR Rules
or “soft” alerts. However, the categories
• Drug-Drug Interactions marked in the table above by an asterisk,
• Drug-Disease Interactions may be administered as “hard” alerts when
• Refill Too Soon* consistent with the client’s benefit
• Drug-Gender management policies.
• Maximum Daily Dose*
• Drug-Age Patient-specific Concurrent DUR for
• Seniors Max Daily Dose* Over-the-Counter Medications
• Under-Utilization
• Cyclic Max Dose* In the third quarter of 2002, Medco Health’s
• Under Minimum Daily Dosage Concurrent DUR program will be able to
• Duplicate Therapy evaluate OTC drugs when purchased via
• Drug-Pregnancy our Internet site or home delivery
• Drug-Allergy Interactions pharmacies for potential safety issues
• Sound Alike/Look Alike when taken in combination with the patients
• Severe Drug-Drug Interactions* prescribed medications. This capability is
unique and proprietary to our web site and
* These rule categories offer option of hard or
soft alerts
 Drug Utilization Review
Clinical programs for health, safety, and cost containment

we are the only source on the Internet Retrospective Drug Utilization Review
which will allow a member to purchase (Retrospective DUR)
OTCs, while receiving real-time drug
utilization review against a personalized Merck Medco’s Retrospective DUR
prescription drug history. involves the analysis of historical data in
order to alert physicians to their
With this capability, patient friendly prescribing within their practice and in
messages will be generated to the the care of specific patients. Alerts that
patient regarding potential drug identify specific opportunities to reduce
interactions. Also, the pharmacist will risk, improve the quality of care and
receive an interaction warning when the lower costs are communicated to
patient’s prescription medications interact physicians in the form of:
with their OTC medications. The
• Patient-specific Messaging (Alerts)
pharmacist can then call the patient or
the doctor and inform them of the • Physician Practice Summaries
potential issue. (Profiles)
• High Utilization Management
We have partnered with CVS.com to
(Investigations)
offer OTC and general health products
for Medco Health plan members via the Patient-specific Messaging
Internet. Members are able to purchase
OTCs, vitamins, and nutritional Patient-specific Messaging involves the
supplements at their own expense via retrospective review of patient-level
Medco Health’s Internet site at prescription claims data to identify drug
www.medcohealth.com. prescribing and/or drug utilization
patterns that may indicate inappropriate
or unnecessary use of certain
Drug Utilization Review with prescription drugs. The program
Pharmacists identifies prescribing, dispensing, and
Drug Utilization Review with Physicians consumption patterns that may not
provides patient-specific and practice- meet established clinical practice
specific information and decision support guidelines. Issues identified include:
to prescribers. This information can be • Drug-Drug Interactions
communicated both at the time the
• Dose Considerations
prescription is written, via point-of-care
• Quantity Considerations
prescribing systems, and following a
retrospective analysis of prescribing and • Therapy Duplication
utilization patterns (Retrospective DUR). • Drug-Age Considerations
Unfortunately, the use of real-time DUR • Drug-Disease Interactions
at the point of care is not widespread. • Potential Misuse & Abuse
 Drug Utilization Review
Clinical programs for health, safety, and cost containment

As described below, Medco Health Physician Practice Summaries

provides physicians with relevant Administration
information that they may not normally
have access to, and that can help to Medco Health focuses this tool on
ensure that members receive the right identifying physicians for whom
drug, at the right dose, for the right prescribing changes represent the most
amount of time. significant savings opportunities for the
plan. In general, 7% of prescibers
Patient-specific Messaging - account for 75% of all savings
Administration opportunity. The Physician Practice
Summaries informs these physicians
Patient-specific Messages are of:
generated via a proprietary clinical
database and rules engine, the Clinical • Prescribing patterns relative to their
Decision Support SystemSM (CDSS), to peers
review Medco Health’s patient profiles • Considerations for future prescribing
for the issues described earlier. When that are specific to the physician’s
issues worthy of communication are practice
identified the physician is notified via • Opportunities for quality
mail. Physicians’ satisfaction and improvement and cost savings
acceptance are tracked by various
means. Changes in therapy and Physician Practice Summaries –
associated savings are identified and Capabilities and Components
reported based on subsequent claims
information. • Prescribing Guidelines: clinical rules
for defining quality and cost effective
Physician Practice Summaries prescribing
Physician Practice Summaries, often
referred to as physician profiles, is a • Profiling Process: each provider’s
retrospective drug utilization review tool prescribing patterns are calculated
that examines and informs physicians by applying the prescribing
about their prescribing patterns. This guidelines against provider and
program focuses on identifying and prescription claim databases
communicating with those specific
physicians with the greatest opportunity • Prescriber Segmentation:
for improvement. Physician Practice prescribers are segmented based on
Summaries provide information that prescription volume and potential
can help physicians improve the quality savings opportunities or other client-
and cost effectiveness of specific criteria
pharmaceutical use.
 Drug Utilization Review
Clinical programs for health, safety, and cost containment

• Physician Practice Summaries and • Investigation Module

Performance Reports are generated.
The Practice Summaries are direct In this module, Medco Health
communications to physicians pharmacists review the utilization of
designed to influence prescribing patients identified via the
behavior. These reports provide each Identification Module. The
physician with prescribing statistics investigations frequently involve
for specific therapeutic areas. The contact with the dispensing
Physician Performance Reports, pharmacy and prescribing physician.
which analyze prescriber If appropriate, the pharmacists make
concentration, prescribing recommendations to address the
performance, and savings opportunity identified issues and problems.
for each prescribing guideline, by
prescriber and in aggregate, are Both modules are designed to promote
provided to clients. quality of care and cost-containment
objectives by identifying poorly
coordinated care, potential abuse of
High Utilization Management drugs and fraudulent use of the
Medco Health’s High Utilization pharmacy benefit.
Management is a retrospective drug
utilization review program for identifying High Utilization Management
and acting to correct over-utilization. Administration
This program consists of two distinct
modules: The Identification Module is available
as a series of High Utilization Alerts
• Identification Module published in EXPERxT. The queries
examine the counts of a combination of
This module identifies patients claims, physicians, pharmacies, days
dispensed quantities of drugs in supply, and drug spend within specific
excess of pre-determined therapeutic categories with the
thresholds. The case identification potential for high abuse. These queries
algorithm examines counts of a are highly flexible and may be modified
combination of claims, physicians, by the user in EXPERxT.
pharmacies, days supply and drug
spend within specific therapeutic For clients who enroll in the
categories with the potential for Intervention Module , Medco Health
abuse. The output report is pharmacists perform reviews to identify
available via EXPERxT. and document cases of over-utilization.
 Drug Utilization Review
Clinical programs for health, safety, and cost containment

These pharmacists utilize a proprietary If, during the investigation process, the
algorithm to calculate a combination of pharmacist identifies a true utilization
claims, physicians, pharmacies and problem, the pharmacist may
days supply for specific therapeutic recommend corrective action(s) to the
categories with the potential for high client. However, discussion with the
abuse. prescribing physician and/or dispensing
pharmacist is often sufficient.
After patients are identified, Medco Corrective action recommendations
Health staff contacts the dispensing include, but are not limited to:
pharmacists and prescribers to initiate
• Limiting the patient to one pharmacy
clinical discussions to evaluate and
determine the appropriateness of the • Limiting the patient to a single
patient’s utilization. prescriber
• Limiting drug-specific coverage for
After gathering the data, the clinical the individual patient
pharmacy staff documents and • Referring the patient to the client’s
analyzes their findings. If during this
Employee Assistance Program
process the pharmacist finds that the
utilization is clinically necessary, the
Clients receive written reports of all
intervention ends, but Medco Health
reviews and investigations, including
continues to monitor and track the
the recommendations and results of
patient's utilization.
each intervention.

© 2001, Medco Health Solutions, Inc. All Rights Reserved. Medco Health Solutions, Inc. is a
subsidiary of Merck & Co., Inc.