• Purpose: Determine contraindications between medications, appropriateness and effectiveness of medication(s) and dosage, cumulative effects of multiple medications, identification of experimental (non-FDA approved) drugs or uses (off-label), causal relationship to WC, weaning recommendations, tool for arbitration and settlement
• Scope:
  • Pain management regimen (past, present and anticipated or requested)
  • No limit on the drugs to be reviewed or questions from the requester
• Reviewer: Active practice MD
• Inputs:
  • Medical records (no limit)
  • RX scripts and bills
  • Other reviews like DUR
  • Peer-to-peer discussion
  • Evidence Based Medicine
  • Reviewer’s active clinical and academic experience
  • Latest medical research
• Discussion: Unless otherwise stipulated by the customer, all prescribing physician(s) will be contacted and receive a copy of the report
• Options:
  • Written agreement on recommended modifications
  • Adjudication Action Plan (managed by CPCU & RN)
  • Prescribing Physician follow-up
  • Recommendations Enforcement (update PBM POS)

NOTE: This can be done in lieu of or in conjunction with a pharmacy network Drug Utilization Review (DUR).