IEHP Safe Rx Pharmacy campaign promotes Safe Rx practice. One of the main components in Safe Rx Pharmacy Campaign is to enhance the DUR process.
Drug Utilization Review (DUR) alerts provides patient safety information to pharmacists at the point-of-sales (POS). Proper DUR management will help prevent adverse or medication-related events. Tier 2 focuses on proper oversight of all Drug Utilization Review (DUR) alerts. P4P payments will be based on appropriate screening and management of DUR alerts.
Pharmacists will be required to review all relevant DURs, screen and determine the most appropriate interventions, and override using DUR PPS codes below.
These four prospective DUR elements below have been selected to be the new core measures of the IEHP Pharmacy P4P Program in order to ensure appropriate clinical care at pharmacy point-of-sale.
- High Risk Medications in the Elderly
- Drug-Drug Interactions
- High Dose
- Therapeutic Duplication
Pharmacy providers will have the opportunity to utilize pharmacy service codes to override at point-of-sale, if appropriate, and to reach out to the prescriber, if needed.
High Risk Medications in the Elderly (HRM)
The American Geriatrics Society (AGS) publishes a list of potentially inappropriate medications for older adults known as Beers Criteria, which was last updated in 2015. Currently, IEHP utilizes this reference to define formulary drugs that are deemed high-risk for IEHP Medicare members who are 65 years of age or older. We recommend to apply the same reference to IEHP Medi-Cal formulary drugs as well, which includes the drugs listed below.
First DataBank (FDB) stratifies drug-drug interactions into four severity levels, ranging from contraindicated to undetermined. FDB defines Severity Level 1 drug-drug interactions as drug combinations that generally should not be dispensed or administered to the same patient. Currently, IEHP allows Severity Level 1 drug-drug interactions to process at point-of-sale. However, given the severity of the interaction, we recommend to block Severity Level 1 drug-drug interactions.
FDB maintains dosing modules that are designed to identify potentially incorrect dosing. These modules obtain their information from several references, including manufacturer documentation and clinical literature, in order to develop recommendations for dosage range. Currently, IEHP allows most drugs to process at point-of-sale if the daily dose submitted is greater than one-times the FDB reference upper limit but less than or at two-times the FDB reference upper limit for all age groups. We recommend to block a subset of drugs if the daily dose submitted is greater than one-times the FDB reference upper limit in order to prevent adverse events associated with high doses. The following therapeutic drug classes were chosen because supratherapeutic doses would either be ineffective, have concerns for abuse, or may cause harm.
- Miotics and Other Intraocular Pressure Reducers
- Ophthalmic Antibiotics
- Eye Antihistamines
- Non-Narcotic Antitussive-1st Generation Antihistamine Combinations
- Anti-Anxiety Drugs
- Otic Preparations, Anti-Inflammatory-Antibiotics
- Selective Serotonin Reuptake Inhibitors
- Proton-Pump Inhibitors
- Narcotic Antitussive-1st Generation Antihistamine
- Antihistamines - 2nd Generation
- Nasal Antihistamine
- Antihyperlipidemic - HMG CoA Reductase Inhibitors
- Non-Narcotic Antitussive-1st Generation Antihistamine-Decongestant
- Skeletal Muscle Relaxants
- Narcotic Antitussive-Expectorant Combination
- Tx For Attention Deficit-Hyperactive(ADHD)/Narcolepsy
- Narcotic Antituss-1st Gen. Antihistamine-Decongest
- Tx For Attention Deficit-Hyperactive(AHD), NRI-Type
- Ear Preparations, Antibiotics
- Narcotic Antitussive-Anticholinergic Combinations
- Tx For ADHD - Selective Alpha-2 Receptor Agonist
- Non-Narcotic Antitussive-Decongestant-Expectorant Combinations
- Antitussives, Non-Narcotic
FDB utilizes specialized therapeutic drug classes to detect duplicate therapy. FDB defines duplicate therapy as unintentional duplication “use” indications, duplicative pharmacology, or duplicative mechanisms of action that not considered “adjunctive therapy.” Duplicate therapy not only indicates inefficient use of medications, but also indicates potential medication risk to the member. For these reasons, we recommend to block therapeutic duplication for certain drug classes. The following therapeutic drug classes were chosen because members should not be on more than one drug within the therapeutic drug class, with the exception of anticonvulsants, where members may receive up to two drugs. The allowances indicate having multiple drugs within the category allowable prior to denying for POS resolution. This takes into account where certain therapeutic classes as part of therapy maybe on more than one medication for treatment.
*Please note 0=Allowance would deny same ingredient as well.
Pharmacy DUR Performance Report Section (Will be available in 2018)
For any questions regarding Pharmacy P4P payments or reports please contact: PharmacyP4P@iehp.org