The UM program and PDL is vital to the utilization management strategy for point-of-sale and physician-administered drugs available via the Fee-For-Service benefit. An effectively and efficiently managed Pharmacy Program will provide savings and promote clinical care and prescribing habits based on best practices.

2025年1月17日 · In this module, participants will learn about the errors generated by the Prescription Drug Front-End System (PDFS) and the Drug Data Processing System (DDPS). Specifically, this module will describe the types of edits and checks performed by PDFS and DDPS and how these edits and checks are applied to the submitted data.

Effective December 1, 2017, Optum Rx Commercial and Managed Medicaid clients were enrolled in our new enhanced Concurrent Drug Utilization Review (CDUR) edits. Soft rejects due to these edits return a message stating “DUR Reject Error,” followed by the reason for clinical concern.

Fill edit by submitting “ER” in field 439-E4. Possible non-matching overrides for “ER” conflicts are below. Review the Response field 544-FY- (DUR Free Text Message) which displays the next earliest date of service that the drug may be filled. Also for ER conflict edits only, if the conflicting fill was filled by a different

We announced the implementation of new drug and biologic edits in the February 2024 issue of Provider News. These drug and biologic edits complement other medication management strategies and help support appropriate medication use and accurate claims submission.

To help prevent and address prescription opioid overuse through improved concurrent DUR, sponsors can fulfill 42 CFR 423.153(c)(2) by implementing opioid safety edits at the POS,1 including: . Soft edit for duplicative long-acting (LA) opioid therapy.

2025年3月1日 · Update: Drug claims edits to focus on FDA‑approved indications Beginning April 1, 2025, claims processed and submitted with pharmaceutical drug procedure codes must be supported by an approved FDA indication or an approved off‑label indication as listed in the CMS-defined list of pharmaceutical compendia.

2018年4月19日 · Enhanced point -of-sale/CDUR edits help ensure a pharm acist safety check at the point -of-sale to screen for dangerous opioid combinations and excess dosing. • Concurrent use of opioids and prenatal vitamins: Designed to identify opioid prescriptions for consumers currently receiving prenatal vitamins, this edit helps prevent the rapidly rising

2024年2月1日 · New drug edits will soon be implemented in our second pass claims editor later in March 2024 and throughout the remainder of the year. These upcoming edits will address such topics as the frequency of drugs billed for Pompe disease, correct diagnosis coding for select immune globulin drugs, and the billing of specialized monoclonal antibody ...

Pharmacy Services provides a variety of safety edits to promote the use of the right medication, in the right patient, at the right time. These edits are routinely updated as new medication entries come to market and in cases of new medication safety alerts in an effort to maintain best-in-class safety protocols.