Utilization Management Program

The most accurate edits point out risks to members and waste to the client. All criteria are created and updated by our P&T Committee based on FDA indications, Micromedex Effectiveness and Safety Info, and primary literature review. Our set of programs include:

1-DUR Program: Through our exception tool in OneArk™, we have created the most accurate edits, so we are able to recommend the rejection of real DURs that represent a real risk of harm to the member or a waste to our client.

2- PA Program: PharmPix’s Prior Authorization Program was designed to assure the right patient is getting the right drug at the right time, in the right dose, for the right extension of time.

We place special attention on efficacy and safety, for example:

• Enbrel: A costly drug indicated for RA. The criteria for approval include, among others, to assess the member’s profile for recent flu like symptoms or active infection medications. “This medication can be harmful to patients with active infections, increasing the dead risk”. If an active infection is confirmed, we recommend holding approval until the healing is done.
• Forteo: A costly medication indicated for osteoporosis. The criterion includes assessing the effectiveness of the drug 6 months after the member starts taking the drug. It is well known that if the medication has not worked within the first 6 months of therapy, it never will.

3- Step Therapy Program

4- Qty Limits (same as DUR and ST)

5- Time Duration

PharmPix’s Step Therapy, Qty Limit and Time Duration Programs are created by our Clinical Team based on primary literature and clinical guidelines. The programs are then reviewed and approved by our independent P&T Committee. We accommodate clients’ criteria per client request.