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Drug Utilization Review

PerformRx's multifaceted Drug Utilization Review program, PerformDUR, helps to ensure that prescriptions for member drugs are appropriate, medically necessary, and unlikely to result in adverse medical consequences. Our program provides the health plan with the control necessary to achieve specific utilization management and financial goals.

PerformRx's concurrent, retrospective, and prospective DUR programs provide our customers with the ability to minimize the number of potentially dangerous conditions that result from improper drug utilization by members. We achieve this objective by examining high cost claims in the following ways:

• Reviewing prescription claims for therapeutic appropriateness prior to medication dispensing
• Applying criteria that include the member's medical history and clinical parameters
• Focusing on members with conditions that place them at the highest level of risk for potentially harmful outcomes

Concurrent DUR

PerformRx applies concurrent DUR edits at the point-of-sale through our claims processing system, along with prior authorization, step therapy, and quantity limit protocols that notify network pharmacists of drug interactions and their severity levels. Inappropriate prescriptions are rejected at the point-of-sale to help prevent instances of fraud, misuse or abuse. In addition, PerformRx reviews compliance rates, and will act in conjunction with the plan to suggest improvements.

The PerformDUR system allows modifications to quantity limits and days supply without the need for programming changes. It is a flexible system, which provides a variety of logic and standards such as early refills, and the capability to track early refills based on current and cumulative usages.

Retrospective DUR

PerformDUR's retrospective DUR program provides systematic review of drug utilization and prescribing patterns to ensure member prescriptions are appropriate, medically necessary, and unlikely to result in adverse medical effects. Unlike concurrent DUR, which occurs at the point-of-sale, our retrospective DUR program examines past prescribing patterns for program enhancements.

Prospective DUR

Prospective DUR is typically conducted in conjunction with the health plan prior to dispensing and can be used to detect drug-specific problems such as dosage problems or duration issues. The goal of the prospective DUR program is to optimize appropriate prescription use while improving overall quality of care.