- Develop customized medication plans
- Establish comprehensive utilization management programs
. Retrospective drug utilization reviews and clinical intervention programs– Conducting retrospective drug utilization reviews, physician monitoring and clinical intervention programs should be used to continually evaluate claims for grey zone medications and monitor inappropriate and/or excessive use. Staying on top of potential patterns can cut back on unnecessary spending and ensure injured worker safety.
. Clinical intervention programs– Seek a PBM that offers a wide range of clinical intervention programs to assist with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions and peer reviews. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation.
- Physician monitoring
- Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines
- Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA approved generic equivalent exists
- Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns
- Pharmacist support
- Nursing support
- Claims professional education
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