Preferred Medical Network - One Source. Many Solutions.

Drug Utilization Review (DUR)

At PMN, we understand the significant role that DUR plays in work comp Rx claims administration. Most plans attribute a 10-20% cost avoidance due to DUR programs, especially when used with quantity limit programs. Our DURs incur no separate fees.

Our analysis includes mail order and retail pharmacy in order to capture your entire organization's utilization. This complete picture allows the best opportunity for program enhancements, new feature introductions and management opportunities such as the quantity limitation programs. It also permits us to correct issues such as inappropriate drug use by patients or prescribing physicians with remedies that may include:

  • Patient education
  • Clinical pharmacist consultation
  • Physician letters
  • Physician phone calls

DUR reporting is done on a quarterly basis. Plus, you may elect hard edits for any or all of our DUR programs.

Three-tier approach to DURs

Verifications done in seconds:

  • Pharmacy participation verification
  • Group eligibility verification
  • Member eligibility verification
  • Group specific exclusions
  • Clinical prior authorization

Any of the following will halt processing and require a call to PMN for verification:

  • Refill too soon
  • Exact duplicate claim, duplicate drug or duplicate class therapy
  • Drug gender edit
  • Geriatric and pediatric minimum/maximum dosing
  • Drug interaction or allergy
  • Drug-to-disease or implied disease contraindication
  • Over/under utilization of therapy
  • Dollar limits per claim or compound claim
  • Quantity or days supply limits per claim
  • Measure physician prescribing based on accepted guidelines through formulary compliance reports
  • Provide physician drug information programs to help promote appropriate, cost-effective prescribing and drug therapies
  • Vital plan-specific utilizations and financial information through semi-annual Rx utilization snapshot reports of the group
  • Retroactive provider reprocessing
  • Retrospective clinical case review
  • Prospective review
  • Concurrent review
  • Retrospective review