Claims : Drug Utilization Review

Prospective Drug Utilization Review

Prospective Drug Utilization Review System

To help individual pharmacies comply with their prospective DUR responsibility, BadgerCare Plus, Wisconsin Medicaid, and SeniorCare developed a prospective DUR system. The system screens certain drug categories for clinically significant potential drug therapy problems before a drug is dispensed to a member. Prospective DUR enhances clinical quality and cost-effective drug use.

Prospective DUR is applied to all BadgerCare Plus, Medicaid, and SeniorCare real-time POS noncompound drug claims submitted to ForwardHealth. Prospective DUR alerts are returned on a claim response to pharmacy providers as a conflict code. The ForwardHealth Payer Sheet: NCPDP Version D.0 or the Prospective Drug Utilization Review Alerts data table on the ForwardHealth Portal has more information about prospective DUR. The data table lists the active prospective DUR alerts that may return on a real-time POS noncompound drug claim response and require clinical review by the pharmacy provider.

Although the prospective DUR system alerts pharmacy providers to a variety of potential problems, it is not intended to replace pharmacists' professional judgment. Potential drug therapy problems may exist which do not trigger the prospective DUR system. Prospective DUR remains the responsibility of the pharmacy, as required by federal and state law. The system is an additional tool to assist pharmacists in meeting this requirement.

Claims Reviewed by the Prospective Drug Utilization Review System

Under the prospective DUR system, only reimbursable noncompound drug claims for BadgerCare Plus, Medicaid, and SeniorCare members submitted through the real-time POS system are reviewed. Although paper claims and compound drug claims are not reviewed by the prospective DUR system, pharmacy providers are still required under provisions of OBRA '90 to independently perform prospective DUR.

Claims for Assisted Living Facility, Group Home, and Nursing Facility Members

Noncompound drug claims submitted through the real-time POS system for assisted living facility, group home, and nursing facility members are reviewed through the prospective DUR system. Providers are required to include a separate DUR segment for all prospective DUR alerts for members in an assisted living facility, group home, or nursing facility, with the exception of insufficient quantity (NS or three-month supply), high cumulative dose (HC or high MME), and underuse precaution (LR or Late Refill). The assisted living facility, group home, or nursing facility pharmacist consultant is responsible for prospective DUR.

Overriding Prospective Drug Utilization Review Alerts

If it is clinically appropriate to dispense the drug, an override by the pharmacy provider is needed to obtain reimbursement from ForwardHealth. Some prospective DUR alerts may require the pharmacy provider to obtain an override from the DAPO Center. Prospective DUR also allows pre-overrides by the pharmacy provider as long as the member's supporting history (that is, drug paid claims history or the ICD diagnosis code on the member's pregnancy or disease profile) corresponds with the pharmacy location that is dispensing the drug.

Pharmacy providers must include a separate DUR segment for each unique type of prospective DUR alert that is returned on a real-time POS noncompound drug claim response from ForwardHealth in order to override the alert(s) and obtain reimbursement.

When a noncompound drug claim is processed with a drug that has the potential to cause problems for a member, the claim response may return multiple prospective DUR alerts to inform the pharmacy provider about each potential problem. Pharmacy providers must include a separate DUR segment for each unique type of prospective DUR alert returned on a claim response and resubmit the claim to ForwardHealth to obtain reimbursement. ForwardHealth recommends that the pharmacy provider document the reason(s) for overriding each unique type of prospective DUR alert.

For example, if three prospective DUR alerts are returned on a claim response, two drug-drug interactions (DD) and one underuse precaution (LR or Late Refill), the pharmacy provider must include a separate DUR segment for one DD prospective DUR alert and the LR prospective DUR alert.

The pharmacy provider must include the following fields within the DUR segment of the NCPDP Version D.0 transaction for each unique type of prospective DUR alert that returns on the claim response:

• Reason for Service Code (Field 439-E4)
• Professional Service Code (Field 440-E5)
• Result of Service Code (Field 441-E6)

Providers are strongly encouraged to contact their software vendors to ensure that they have access to these necessary fields. The ForwardHealth Payer Sheet: NCPDP Version D.0 has information about NCPDP transactions.

Multiple Prospective Drug Utilization Review Alerts That Include an Informational Prospective Drug Utilization Review Alert

When multiple prospective DUR alerts are returned on a claim response and one of them is an informational prospective DUR alert, such as insufficient quantity (NS or three-month supply), the pharmacy provider must include a separate DUR segment for each unique type of prospective DUR alert, except the informational prospective DUR alert.

For example, if three unique types of alerts are returned on a claim response, pregnancy (PG), DD, and NS, the pharmacy provider must include a separate DUR segment for the PG and DD prospective DUR alerts and resubmit the claim to ForwardHealth to obtain reimbursement. The NS prospective DUR alert, which is informational, does not require a response by the pharmacy provider.

Multiple Prospective Drug Utilization Review Alerts That Include an Override From the Drug Authorization and Policy Override Center

When multiple prospective DUR alerts are returned on a claim response and one of the alerts is an overuse precaution (ER or Early Refill) prospective DUR alert, the pharmacy provider may need to contact the DAPO Center to obtain an override for the ER alert. If one of the alerts is a non-informational insufficient quantity (NS or three-month supply) prospective DUR alert, the pharmacy provider must contact the DAPO Center to obtain an override for the NS alert. Additionally, pharmacy providers must include a separate DUR segment for each unique type of prospective DUR alert returned on the claim response, except the ER or NS prospective DUR alert. Pharmacy providers should not include a DUR segment for an ER or NS prospective DUR alert that requires an override from the DAPO Center.

For example, if three unique types of alerts are returned on a claim response, reported disease (MC or drug-disease contraindication), DD, and a non-informational NS alert, then the pharmacy provider must contact the DAPO Center to obtain an override for the non-informational NS prospective DUR alert and also must include a separate DUR segment for the MC and DD prospective DUR alerts before resubmitting the claim to ForwardHealth to obtain reimbursement.

Note: Certain drugs monitored by the NS prospective DUR alert are not informational and require the pharmacy provider to contact the DAPO Center to obtain an override.

Pre-Overriding Prospective Drug Utilization Review Alerts

Prospective DUR allows pre-overrides in the following scenarios:

• A pharmacy provider may pre-override a TD, DD, LR, HC, or ER alert if a drug in the member's drug paid claims history at that pharmacy location will activate a prospective DUR alert for a drug currently being dispensed by the pharmacy.
• A pharmacy provider may pre-override a PG or MC prospective DUR alert if the pharmacy previously submitted a drug paid claim with an ICD diagnosis code that created a pregnancy or disease profile for the member, and they are currently dispensing a drug that will activate a prospective DUR alert.
• A pharmacy provider may pre-override the drug-age precaution (PA or patient age) prospective DUR alert without a drug paid claims history requirement.

Prospective DUR does not allow pre-overrides when the member does not have the necessary supporting drug paid claims history at the same pharmacy location or when the prospective DUR alert requires an override from the DAPO Center.

For example, if the pharmacy provider includes two DUR segments to pre-override two types of alerts, PG and DD, on a claim and an LR prospective DUR alert is returned on the same claim response, then the pharmacy provider must include a separate DUR segment for each unique type of prospective DUR alert, including the PG and DD prospective DUR alerts that were pre-overridden, and resubmit the claim to ForwardHealth to obtain reimbursement.

Alerts and Alert Hierarchy

The DUR Board established a hierarchy for the order in which multiple prospective DUR alerts appear if more than one prospective DUR alert is returned on a real-time POS noncompound drug claim response. Factors taken into account in determining the hierarchy include the potential for avoidance of adverse consequences, improvement of the quality of care, cost savings, likelihood of a false positive, retrospective DUR experience, and a review of prospective DUR alerts used by other state Medicaid programs for prospective DUR. The clinical drug tables used to establish the prospective DUR alerts are provided to BadgerCare Plus, Wisconsin Medicaid, and SeniorCare by First DataBank, Inc.

Prospective DUR alerts that identify a potential drug therapy problem are returned on a claim response. These prospective DUR alerts are listed in hierarchical order according to the following prospective DUR conflict codes:

• PA (Drug-age precaution)
• DD (Drug-drug interaction)
• MC (Reported disease)
• TD (Therapeutic duplication)
• PG (Pregnancy alert)
• ER (Overuse precaution)
• HC (High cumulative dose)
• LR (Underuse precaution)

Informational Prospective Drug Utilization Review Alerts

Some prospective DUR alerts are informational. Informational prospective DUR alerts will be posted on the real-time POS noncompound drug claim response but will not cause the claim to deny. These prospective DUR alerts are intended to provide the dispensing pharmacy with the DUR information without causing a claim denial. Insufficient quantity (NS or three-month supply) is the current informational prospective DUR alert. Of note, certain drugs monitored by the NS prospective DUR alert are not informational and require the provider to contact the DAPO Center to obtain an override.

Drug-Age Precaution

The drug-age precaution (PA or patient age) prospective DUR alert is returned on a real-time POS noncompound drug claim response when claims include any products containing codeine or tramadol or prescription cough and cold products containing codeine or hydrocodone if the member is less than 18 years of age.

Pharmacy providers should assess whether it is clinically appropriate to dispense the product for the child prior to entering an override to proceed. Pharmacy providers must include a DUR segment for the prospective DUR alert to obtain reimbursement.

Drug-Drug Interaction

The drug-drug interaction (DD) prospective DUR alert is returned on a real-time POS noncompound drug claim response when another drug in ForwardHealth drug paid claims history interacts with the drug being filled. The system reviews not only the prescriptions at the current pharmacy, but all of the prescriptions reimbursed by BadgerCare Plus, Wisconsin Medicaid, and SeniorCare.

DD is defined as a pharmacological response in a patient taking two drugs that differs from the expected pharmacological response when each drug is taken separately.

Note: The history claim and current claim must be from a different pharmacy or prescriber.

High Cumulative Dose

The high cumulative dose (HC or high MME) prospective DUR alert is returned on a real-time POS noncompound drug claim response when a drug being dispensed has a dose that is equal to or greater than 90 MME on the current claim.

Daily MMEs are approximated using a calculation based on the drug ingredient, strength, and the days' supply indicated on the noncompound drug claim. This prospective DUR alert does not calculate a cumulative daily MME and does not consider other opioids the member may be taking. Buprenorphine products, all opioid liquids, and methadone for medication-assisted therapy will be excluded from the prospective DUR alert; however, methadone for pain will be included in the prospective DUR alert.

Pharmacy providers will be required to respond to the HC prospective DUR alert to obtain reimbursement. Pharmacy providers should perform an appropriate review and counseling considering the member's overall medication use before dispensing the drug to the member.

Insufficient Quantity—Three-Month Supply

The insufficient quantity (NS or three-month supply) prospective DUR alert is an informational prospective DUR alert that informs pharmacy providers that there is an opportunity to dispense a drug in a three-month supply. Certain drugs are required to be dispensed in a three-month supply, while other drugs are allowed to be dispensed in a three-month supply. Pharmacy providers are not required to include a DUR segment for the NS informational prospective DUR alert.

For drugs that are required to be dispensed in a three-month supply, pharmacy providers are required to call the DAPO Center to obtain an override to dispense less than a three-month supply.

Overuse Precaution

The overuse precaution (ER or Early Refill) prospective DUR alert for a claim returned on a real-time POS noncompound drug claim response when the drug, drug strength, and dosage form on that claim matches the drug, drug strength, and dosage form on another claim in ForwardHealth drug paid claims history for which the threshold percentage of the days' supply has been used on the prescription fill/refill. The prospective DUR alert will indicate the date that the drug can be refilled without returning the prospective DUR alert.

All drugs will be subject to this prospective DUR alert, with the exception of:

• Drugs listed on the Quantity Limit Drugs and Diabetic Supplies data table.
• Drugs with a five days' supply or less.

Pharmacy providers must include a DUR segment for the prospective DUR alert to obtain reimbursement.

For certain drugs monitored by the ER prospective DUR alert, pharmacy providers are required to call the DAPO Center to obtain an override. A comprehensive list of drugs monitored by the DAPO Center for the ER prospective DUR alert is available to providers on the Pharmacy provider-specific resources page of the Portal. The thresholds described above also apply to ER prospective DUR alerts that must be overridden by the DAPO Center.

Early Refill—Drug Authorization and Policy Override

Examples of when an ER override request may be approved through the DAPO Center include the following:

• The member has an appropriate medical need (for example, the member's medications were lost or stolen, the member has requested a vacation supply, or the member was involved in a natural disaster).
• The member has been taking too much of a medication because they misunderstood the directions for administration from the prescriber.
• The prescriber changed the directions for administration of the drug and did not inform the pharmacy provider.

If the DAPO Center determines that it is not appropriate to refill the drug early, the pharmacy may instruct the member to return to the pharmacy to pick up the refill after the proper threshold percentage of the days' supply has been taken. Providers may refer to NCPDP field 544-FY (DUR Free Text Message) to determine the date the member may pick up the refill of a drug.

Pregnancy Alert

The pregnancy (PG) prospective DUR alert is returned on a real-time POS noncompound drug claim response when a drug being dispensed has a potentially dangerous effect on a pregnant member.

This prospective DUR alert is returned on a claim response when all of the following conditions are met:

• ForwardHealth receives a medical or noncompound drug claim for the member that indicates pregnancy using a diagnosis code.
• A noncompound drug claim for a drug that possesses a clinical significance code of D, X, or 1 (as assigned by the FDA or First DataBank, Inc.) is submitted for the member.

The pregnancy diagnosis will be deactivated from a member's pregnancy profile after 260 days or if an intervening diagnosis indicating delivery or other pregnancy termination is received on a claim.

Reported Disease

The reported disease (MC or drug-disease contraindication) prospective DUR alert is returned on a real-time POS noncompound drug claim response when a drug being dispensed has a potentially dangerous interaction with a reported disease. Disease profiles are created for members using diagnosis information from medical, institutional, and noncompound drug claims. Diseases are assigned a duration of acute, chronic, or lifetime. Acute diseases remain in the member's disease profile for 120 days, chronic diseases remain for 200 days, and lifetime diseases remain permanently.

Therapeutic Duplication

The therapeutic duplication (TD) prospective DUR alert is returned on a real-time POS noncompound drug claim response when a drug being dispensed has the same therapeutic benefit as a previously dispensed drug.

This prospective DUR alert is returned on a claim response when all the following apply:

• A drug is present in drug paid claims history in the same therapeutic category as the drug being dispensed.
• The drugs have the same therapeutic category but have a different active ingredient.
• The DOS of the two interacting drugs overlap.
• The history claim and the current claim must be from a different pharmacy or prescriber.

The message sent to the provider includes the drug name in drug paid claims history that is causing the prospective DUR alert. Refer to the table below for the therapeutic categories monitored for the therapeutic duplication prospective DUR alert.

Underuse Precaution

The underuse precaution (LR or Late Refill) prospective DUR alert is returned on a real-time POS noncompound drug claim response when a drug being dispensed is being refilled less than what is recommended. The prospective DUR alert is returned on a claim response when the drug being refilled exceeds 120% of the days' supply on the same drug in ForwardHealth drug paid claims history.

The number of days late is calculated as the days after the prescription should have been refilled. Claims in drug paid claims history must be for greater than or equal to 28 days' supply to be included in this prospective DUR alert.

Refer to the table below for the therapeutic categories monitored for the underuse precaution prospective DUR alert.