Self-insured employers and some insurers with a good medical management program providing utilization reviews for medical treatments and medical procedures often fail to have a prescription drug utilization management program. Prescription drugs are the fastest growing component as a percentage of total medical costs.
Injured employees prescribed multiple medications to manage pain often have prescription drug costs in excess of $1,000 per month. Employees who need specialty drugs or whose doctors prescribe the latest FDA approved medication also incur substantial prescription costs. A drug utilization review by a highly experienced nurse or physician can often lower prescription costs by identifying prescription activities that can increase prescription costs without providing added benefit to injured employees.
A prescription utilization review can include:
- ·Formulary compliance: A formulary is a list of preapproved medications to be prescribed to any injured employee in need to treat the injury or occupational disease. Utilization review verifies the medications prescribed are pre-approved for use.
- Lower cost alternatives:
– Use of generics drugs when appropriate.
– Substitution of lower cost drugs providing the same treatment benefit as a higher cost alternative drug prescribed.
- Identifying duplicate purpose drug usage: Occurs when the injured employee is prescribed two different medications designed to provide the same benefit. Sometimes a result of physician oversight, occurring more frequently when multiple physicians prescribe medications to the same injured employee.
- Overuse of a prescribed medication: Frequently occurs with narcotics,as well as other drugs, when the employee starts consuming medication at a faster rate than the medical provider prescribed, or consummation is at a higher dose or longer than the manufacturer recommends.
- Off-label use of a drug: A medication prescribed for a purpose other than that of its original intent or design. Off-label usage of a drug requires a nurse or physician skilled in drug utilization review to determine when prescribing such a drug is both appropriate and effective.
- Newly FDA approved drugs: While new drugs are frequently more expensive than drugs on the market for a long period of time, there are situations where the new drug provides superior benefits. The drug utilization review person brings this alternative medication to the attention of the medical provider.
- Regulatory compliance: Drug utilization review verifies the medications being prescribed to the injured employee comply with state statutes.
- Identification of multi-pharmacy duplication: Assists with the identification of inappropriate use, abuse or diversion. As an example, this may be uncovered when an injured employee takes the written prescription to one pharmacy to be filled. Then, the employee calls the doctor’s office, reporting the prescription as lost, and asks for the prescription to be called into a different pharmacy.
- Identification of non-related medications: An injured employee uses the pharmacy benefit card to purchase medications for non-injury related medical problems.
The medical management company an employer uses for prescription reviews should be accredited by the Utilization Review Accreditation Committee (URAC). URAC certification means the medical management company has the skill to promote both quality and efficiency in their utilization reviews.
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: [email protected].
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