The Basics

This standard sets forth the general requirement that the organization's P&Ps address DrUM criteria for such things as: 

• optimal drug use,
• evaluation of the consumer clinical information provided with the authorization request, and 
• review timeliness.

The criteria for evaluating the data submitted by the consumer, prescribing provider, and/or pharmacy along with the request for authorization must:

• address discrepancies between optimal and actual use;
• coordinate intervention when it is appropriate to pursue treatment alternatives; and
• evaluation of program effectiveness.

It is particularly important to understand what URAC means by "Drug Utilization Management", or "DrUM as we'll call it throughout these pages.  It is your organization's evaluation of the "medical necessity, appropriateness, and efficiency of the use of health care services, procedures, products, and facilities under the provisions of the applicable health benefits plan; sometimes called 'drug review.'”  URAC distinguishes this from straight, non-clinical benefit determinations.  So, for example, a benefit exclusion for a particular drug, say, Rogaine, is not DrUM.  On the other hand, a process that looks at a covered drug and determines whether it is medically necessary and/or appropriate for the particular patient is the DrUM process.  

Management Tips

Make sure to draft clear P&Ps that outline: 

• the process of developing the criteria mentioned in this standard, 
• the process used by the DrUM staff members to apply the criteria,
• the timeframes for each component of the DrUM process, from start to finish, 
• safety protocols used in the DrUM program, including the tracking system for outbound communications for safety interventions, 
• a description of the DrUM case tracking mechanism(s), and
• approaches to evaluating the DrUM program for effectiveness.

Mere tracking is not the same as aggregating and evaluation, as is required for the evaluation of effectiveness of the DrUM program.  Therefore, make sure that your tracking mechanisms' data are aggregated and perhaps turned into reports that go to the quality management committee for evaluation.

URAC Accreditation Tips

Each of the six elements of this standard is mandatory.

For the desktop review, submit the applicable P&Ps, organization charts, and any evidence of program evaluation such as reports of such evaluations to the quality management committee.

The onsite review will involve an examination of your current applicable DrUM P&Ps, a demonstration that your staff members can access those P&Ps, interviews (at their desks) of DrUM staff members, and a review of any reports of program effectiveness, probably from minutes of the quality management committee.