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Why does Alaska Medicaid have a Drug Utilization Review program?
Alaska Medicaid’s Drug Utilization Review, (DUR), program was developed in order to comply with the federal requirements set forth in the Omnibus Budget Reconciliation Act of 1990. Prospective and retrospective DUR are required by both
federal and
state law. The State of Alaska contracts with
HMS (Healthcare Management Solutions, LLC) to conduct the DUR program.
Prospective DUR:
Prospective DUR (ProDUR) is performed by all Alaska pharmacists before filling any prescription. Proprietary software developed by the pharmacy claims processor, Prime Therapeutics Health Services, is used to check for potential problems with a Medicaid patient’s medication therapy. This software will bring the pharmacists attention to such matters as drug-drug interactions, therapeutic duplications, early refills, pregnancy cautions, as well as other potential problems.
In response to actual or potential medication utilization issues the Department may implement strategies to address safety, fraud, waste, abuse, misuse or medically unnecessary care. Some of the ProDUR interventions currently used are prior authorizations, step-edits, therapeutic duplication edits and quantity limits. A list of the medications impacted by ProDUR edits can be found at the
Medication Prior Authorization webpage.
Retrospective DUR:
Retrospective DUR is performed by the state’s DUR Committee some time after a prescription is filled. The committee consists of physicians, pharmacists, and other healthcare providers who are actively practicing in the community, as well as 1 pharmacist who is a state employee and coordinates the committee’s activities. The committee meets at least quarterly to review the use of medications by Medicaid recipients, and identify regimens that do not meet predetermined clinical criteria. When an aberrant pattern of prescribing and/or utilization is identified, an educational letter is sent to the prescriber and/or dispensing pharmacist informing them of the potential problem and requesting a reply which explains how the issue will be addressed.
DUR Committee Members
- Valerie Bixler, PharmD
- Casey Gokey, MD
- Dr. Charles Ryan, MD
- Dr. Robert Carlson, MD
- Keri McCutcheon, RPh
- Mathew Begay-Bruno, PharmD
*
If you are interested in serving on the DUR Committee please contact the committee coordinator
DUR Interventions:
Prospective Drug Utilization Review (ProDUR)
The DUR Committee has continued their attention on ProDUR issues. New prior authorizations and quantity limit edits were approved to address issues of actual or potential fraud, waste, abuse, misuse, overuse or medically unnecessary care. Emphasis was also given to review of existing criteria to ensure relevancy and medical appropriateness. ProDUR interventions are monitored periodically and presented to the committee to assess the success of the intervention and to determine if additional edits are required to address safety or utilization issues. Modifying current edits to other drug classes has been a good tool in maintaining cost effective use of generics and reduce the amount of possible waste and overutilization.
Retrospective Drug Utilization Review (RetroDUR)
The DUR Committee conducts retrospective reviews. The criteria for claims review are frequently selected by the committee coordinator based on trend reports or suggested drug related issues by the committee members. In addition to the selected criteria members review for therapeutic duplication, drug interactions, overutilization, and poly-providers usage. The retrospective reviews periodically unearthed opportunities to consider the development of prospective edits.
RetroDUR issues are generally addressed with educational interventions such as prescriber letters or direct prescriber contact via phone. The logistics of face-to-face interactions with prescribers is difficult due to the large geography of the state with many communities having limited road access. The DUR Committee may also refer potential cases of overutilization or fraud, waste or abuse identified during the RetroDUR to the Care Management program and/or the Program Integrity unit. Relaying relevant prescription information to providers is a challenge. One enhancement the committee is attempting to use to further communicate with providers is automatic emails delivered by GovDelivery. Additionally, data trends identified by other organizations such the FDA (e.g. FAERS reports), Pharmacy Quality Alliance [PQA] (e.g. quality measures), and the Drug Abuse Warning Network [DAWN] (e.g. DAWN reports) have been incorporated to aid in directing our focus on nationally identified issues. Given our smaller relative patient population and regional isolation, trends observed nationally may not have triggered signals in our data. By evaluating nationally identified trends in our own data, we hope to catch the early signals and work on prevention initiatives before they blossom into larger issues.