Medical Management, Quality Assurance, and Other Programs

Participating pharmacies shall participate in and comply with HMSA’s Drug Utilization (DUR) programs designed to ensure the most appropriate and cost-effective use of medically necessary prescription drugs. Such programs include, without limitation:

• Therapeutic duplication: When the combined daily dosage of two or more drugs will not provide added therapeutic benefit to warrant the drug cost
• Drug interactions: When the combined dosage of two or more drugs puts the member at risk for an adverse medical effect
• Incorrect drug dosage or duration: When the dosage prescribed does not comply with accepted standards to achieve a therapeutic effect (e.g., number of days exceeds or falls short of standards)
• Over-utilization: When use of a drug in the prescribed quantity or duration puts the member at risk of an adverse medical reaction
• Drug disease contraindication: When the potential exists for the occurrence of an adverse reaction on the member’s condition or disease
• Drug allergy interactions: When there is significant potential for an allergic reaction for the member for whom a drug is prescribed
• Programs related to Schedule II drugs regulated under the Controlled Substance Act (CSA)

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