Drug Utilization Review (DUR)

Blue Cross and Blue Shield of Oklahoma (BCBSOK) and Prime Therapeutics conduct prospective, concurrent, and retrospective drug utilization reviews to ensure the most appropriate and cost-effective drugs are used safely. Prospective DUR entails provider education through the use of newsletters and personal contact by employees of the plan.

Concurrent DUR occurs at the point of sale (i.e., at the dispensing pharmacy). Pharmacies are electronically linked to Prime Therapeutics' claims adjudication system. This system contains various edits that check for drug interactions, overutilization (i.e., early refill attempts), and therapeutic duplications. The system also alerts the pharmacist when the prescribed drug may have an adverse effect if used by elderly or pregnant members. The pharmacist can use his or her professional judgment and call the prescribing provider if a potential adverse event may occur.

Retrospective DUR uses historical prescription and/or medical claims data to identify potential prescribing and dispensing issues after the prescription is filled. Examples of retrospective DUR include appropriate use of controlled substances and generic utilization programs. These programs aim to promote safety, reduce overutilization and close gaps in care. Retrospective DUR programs are developed based on widely accepted national practice guidelines.

Individual letters may be mailed to providers identifying potential drug therapy concerns, together with a profile listing the member's prescription medications filled during the study period, references to national practice guidelines and/or a response form to be faxed to BCBSOK.