Alaska Medicaid Drug Utilization Review (DUR) Program

Who we are

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. 

What we do

The DUR program is designed to ensure that Medicaid recipients are receiving safe and appropriate medications.

The State of Alaska contracts with Prime Therapeutics to conduct the DUR program.

Types of reviews

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 drug-drug interactions, therapeutic duplications, early refills, pregnancy cautions, and 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 conducted by the state’s DUR Committee after a prescription is filled. The committee, made up of physicians, pharmacists, and other healthcare providers who practice in the community, along with a state-employed pharmacist who coordinates the committee’s activities, meets at least quarterly. They review the use of medications by Medicaid recipients and identify regimens that don't meet predetermined clinical criteria. If an unusual pattern of prescribing or usage is found, an educational letter is sent to the prescriber or dispensing pharmacist, informing them of the potential issue and requesting a response explaining how the matter will be addressed.

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.

The logistics of face-to-face interactions and educational interventions with prescribers is difficult due to the geography and limited road access to many communities. RetroDUR can be provided using prescriber letters or direct phone calls to the prescriber. 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 also a challenge. One communication enhancement for 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 direct 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.

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

Resources