Drug Utilization Review
UMass Medical School's Center for Health Policy and Research provides Drug Utilization Review services for the MassHealth pharmacy program. Drug Utilization Review, part of the federal Medicaid mandate, provides internal controls to ensure subscribers are receiving appropriate and medically-necessary prescription drug therapy in the most cost-effective manner possible.
The program examines claims data for three key conditions:
- Inappropriate prescribing of drugs,
- Abnormal prescribing and dispensing patterns, and
- Adverse drug interactions.
An expert panel of physicians and pharmacists help develop clinical guidelines for the program.
Prospective Drug Utilization Review
Real-time clinical review of prescription requests ensures that pharmacists are aware of safety issues such as possible adverse drug interactions, therapeutic duplications, or even inappropriate dosages. It also provides review of prior authorization requests for appropriate and preferred use of medications.
Retrospective Drug Utilization Review
Retrospective review targets outliers and patterns involving prescribers, pharmacists, and patients after the prescriptions are dispensed. This helps identify abuse or fraud problems, such as so-called doctor shoppers (subscribers seeking multiple pain medication prescriptions from multiple doctors) and in criminal prosecution in the event of fraud. These efforts can also result in educational interventions such as outbound phone calls or letters to doctors to help them improve prescribing behavior.