6 - Drug Utilization Management & Price Control Flashcards
DUR
or DUE
Drug Utilization Review or Drug use Evaluation
program for assessing appropriateness of drug therapy by evaluating date on drug use against some std / predetermined criteria
clinical appropriateness / Cost effectiveness / desired outcomes
3 Types:
Retrospective / Concurrent / Prospective
RETROspective DUR
Review of drug therapy performed
AFTER drug dispensed
COMMON ISSUES
Appropriateness / over-under-utilization / generic use
clinical abuse-misuse / therapeutic duplication / Contraindications
drug-drug interactions / drug dosage / asthma / duration
Concurrent DUR
ONGOING MONITORING** of drug therapy **DURING course of treatment
Common issues:
Drug - drug interactions / excessive doses / too high or too low doses
duplicate therapy / pregnancy / age / gender
WARFARIN + INR monitoring
PROSPECTIVE DUR
Evaluation of a patient’s drug therapy BEFORE a drug is dispensed
Common:
therapeutic interchange / generic substitution
incorrect dosage / DRUG ALLERGY / clinical abuse
Penicillin Allergy
Formulary SYSTEM
Systematically maintained COMPILATIONS
of therapeutically effective pharmaceuticals NECESSARY
for rational patient treatment
Formularies
Continuously updated lists of DRUGS OF CHOICE approved for use in a healthcare facility / benefit plan and
WILL BE REIMBURSED BY THE PAYER
Classified by DEGREE OF RESTRICTIVENESS
Closed / Open / Everythign in between
Tier system
P&T Process / Committees
Pharmacy & Therapeutics
Responsible for establishing & maintaining
DRUG FORMULARIES
Provides guidance on info providede in dossiers to MCOs
Product Info + Disease Discription / Clinical Evidence / Economic Value
Step-Care Protocols / Algorithims
Care Maps / Treatment Algorithims,
CAN BE IN COMBO WITH PRIOR AUTH
PLAN for a prescribed course of treatment in the management of a disease
REQUIRES use of recognized FIRST-LINE DRUG before approval of a more complex second -line drug
Disease State Management
or just Disease Management
Set of ACTIVITIES aimed at
Improving health + Clinical outcomes
of a population of patients defined by all having a CHRONIC MEDICAL ILLNESS
organized through the use of technologies such as
electronic health records / disease registry programs
COPD + Diabetes + Heart Failure + GI Disorders
HYPERcholesterolemia / HT / ESRD / CAD / ASTHMA
DPS
Drug Product Selection
Include
Therapeutic Interchange
drug products with a different chemical structure but are of the same pharmacological/therapeutic class
Generic Substitution
Therapeutic Interchange
Type of DPS
Drug Product Selection
AUTHORIZED EXCHANGE of a drug with a different chemical composition
but the same inteneded THERAPEUTIC OUTCOME as one prescripted
ILLEGAL TO DO WITHOUT PRIOR AUTHORIZATION
Generic Substitution
Use of a version of a generic multisource drug product other than the brand or version subscribed
SAME ACTIVE INGREDIENTS
Chemically IDENTICAL in:
Strength / Concentration / Dosage Form / Route of Admin
BIOEQUIVALENT
ORANGE BOOK
Generic Equivalents = PHARMACEUTICAL EQUIVALENTS
defined in this book
A = NO KNOWN Bioequivalence Problems
AB = Sufficient BioEQ evidence
MAC = Maximum Allowable Cost
Not good news with GENERICS
Health plans + PBMS are increasingly setting MAC pricing
when multiple generic versions are available
MAXIMUM INGREDIENT COST
that will be paid for the drug, regardless of acquisition cost of drug
reimburseed below the acquisition costs for some pharmacies