Prospective DUR (ProDUR) is a review of a person’s medication record and prescription drug orders prior to dispensing.

The ProDUR review of drug therapy is performed before each prescription is filled or delivered to the person, typically at the point-of-sale or point of distribution.  This process assists the pharmacist by addressing situations in which potential drug problems may exist.  ProDUR performed prior to dispensing helps pharmacists ensure that the person receives appropriate medications.  This is accomplished by providing information through messaging from the claim submission system to the dispensing pharmacist that may not have been previously available particularly if the person is using more than one pharmacy.

The prospective review includes:

  • Screening for potential drug therapy problems due to therapeutic duplication
  • Drug-disease contraindications
  • Drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs)
  • Incorrect drug dosage or duration of drug treatment
  • Drug-allergy interactions
  • Clinical prior authorizations
  • Clinical abuse/misuse

HHSC uses the compendia and literature as its source of standards for such review.

The ProDUR processes of the VDP pharmacy claims system examines all pharmacy claims.  As a result, drugs that interact, or are affected by previously dispensed medications, can be detected.  VDP recognizes that the pharmacist uses his or her education and professional judgment in all aspects of dispensing.  ProDUR is offered as an informational tool to aid the pharmacist in performing his/her professional duties.  Most ProDUR edits are driven by day supply, making it important that this field is reported correctly.

2.1 ProDUR Alerts 

Alerts concerning clinically significant drug-drug interactions, therapeutic duplications, ingredient duplications, or maximum dosage are part of the claim adjudication process.

Alerts do not cause claims to reject and are intended to provide information to assist the pharmacist in working with the prescribing provider to provide appropriate pharmaceutical therapy.

Alerts are contained in the “Drug Use Review/Professional Pharmacy Service

(DUR/PPS)” segment in fields noted within Table 1.  Refer to the “NCPDP B1 Transaction Paid Response” and “NCPDP B1 Transaction Rejected Response” payer

sheets for specific transaction, segment, and field requirements.  Download the VDP Pharmacy Provider Payer Sheets.

Table 1 - VDP ProDUR Alerts

NCPDP Field Name

Field #

Value

Reason for Service Code

439-E4

DD = Drug-Drug Interaction
HD = High Dose
ID = Ingredient Duplication
TD = Therapeutic

Clinical Significance Code

528-FS

Blank = Not Specified
1 = Major
2 = Moderate
3 = Minor

Other Pharmacy Indicator

529-FT

Ø = Not Specified
1 = Your Pharmacy
2 = Other Pharmacy in Same Chain
3 = Other Pharmacy

Previous Date of Fill

53Ø-FU

 

Quantity of Previous Fill

531-FV

 

Database Indicator

532-FW

Blank = Not Specified
1 = First Databank

Other Prescriber Indicator 533-FX Ø = Not Specified

1 = Same Prescriber
2 = Other Prescriber

    The system's ProDUR processes assist the pharmacist by addressing situations in which potential drug problems may exist.  ProDUR performed prior to dispensing helps pharmacy staff ensure that the person receives clinically appropriate medications.  This is accomplished by providing information to the dispensing pharmacist that may not have been previously available particularly if the person is using more than one pharmacy.  The system assists pharmacy staff in the prospective review for people enrolled in Medicaid by providing online information on prescriptions paid by VDP within the defined time period. Examples of DUR messages include the clinically significant drug/drug interactions and therapeutic duplications. 

    Prospective (concurrent) drug use review edits apply to all claims unless otherwise identified.

    2.2 DUR Rejections

    The VDP system provides information regarding therapeutic duplication, ingredient duplication, maximum dosage, and significance level 1 and 2 (First Data Bank) drug-drug interactions for those prescriptions paid by Medicaid, CSHCN, or KHC programs. Since some people are limited to a specific number of prescription drug claims per month, the person’s medication record at the dispensing pharmacy must be reviewed to ensure the inclusion of a complete drug history in the prospective DUR process. Drug allergy and disease state information will not be available online, and will also have to be reviewed from the person’s medication record.

    The selected claims with the greatest potential for adverse therapeutic outcomes will reject with NCPDP code “88” ("DUR Reject Error").  Refer to the “NCPDP B1 Transaction Rejected Response” payer sheets for specific field requirements.  Download the VDP Pharmacy Provider Payer Sheets from txvendordrug.com/about/policy/payer-sheets.

    Pharmacy staff will have the ability to override the DUR rejection by submitting the “DUR Reason for Service Code”, “DUR Professional Service Code”, and “DUR Result of Service Code” fields on the claim (see Table 2) if it is determined that the prescribing provider understands the risk to be acceptable, and appropriate monitoring measures are undertaken. The override can also be submitted on the initial claim submittal, if appropriate, thus bypassing the rejection. The override capability will allow payment of the rejected claims when appropriate without pharmacy staff intervention.

    Refer to the “NCPDP B1 Transaction Billing Request” payer sheets for specific field requirements.  Download the VDP Pharmacy Provider Payer Sheets.

    Table 2 - VDP DUR Rejection Override

    Field Name Field Number Accepted Values
    DUR Reason for Service 439-E4

    DD - Drug-Drug Interaction
    HD - High Dose
    ID - Ingredient Duplication
    TD - Therapeutic Duplication

    DUR Professional Services Code 44Ø-E5

    ØØ - No Intervention
    MØ - Prescriber Consulted
    PØ - Patient Consulted
    RØ - Pharmacist consulted other source

    DUR Result of Service Code 441-E6

    1A - Filled As Is, False Positive
    1B - Filled Prescription As-Is
    1C - Filled, With Different Dose
    1D - Filled, With Different Directions
    1F - Filled, With Different Quantity
    1G - Filled, With Prescriber Approval
    4A  - Prescribed with acknowledgement

    Only claims paid through the VDP system will be screened for interactions, duplication, and maximum dosage online. It is necessary that the required Patient Medication Record (PMR) be reviewed for additional drugs not paid by Medicaid, CHIP, CSHSN, or KHC. This is especially important for those people limited to three prescriptions per month. The PMR must also be reviewed by pharmacist to evaluate drug disease contraindications, drug allergy interactions, and duration of drug treatment since this information is not in the VDP system at this time.

    2.3 DUR Result of Service

    Claims that are reversed because of a DUR advisory message must have an accompanying standard “DUR Result of Service Code” value submitted (see Table 3).  These values allow VDP staff to measure the effectiveness of advisories and document action taken by the pharmacist.

    Table 3 - DUR Result of Service Codes Values

    Field Name Field Number Accepted Values
    DUR Result of Service Code 441-E6

    1C - Filled with a different dose
    1D - Filled with different directions
    1E - Filled with a different drug
    1F - Filled with a different quantity
    2A - Prescription not filled
    2B - Not filled, directions clarified

    This value must be submitted on reversals caused by a DUR message because the Centers for Medicare & Medicaid Services (CMS) requires all state Medical programs to demonstrate positive results from online ProDUR.  Pharmacy staff should contact their software vendor for questions relating to the appropriate submission of these codes on reversal transactions.

    2.4 OBRA 90 Requirements for Pharmacies

    OBRA 90 mandates that, effective January 1, 1993, state Medicaid programs require enrolled pharmacies to:

    • Perform prospective drug user review
    • Maintain a person’s medication records (profiles)
    • Counsel people on each new prescription

    The Texas State Board of Pharmacy (TSBP) incorporated the OBRA 90 requirements into the pharmacy rules, adopted December 1992.  Pharmacies in compliance with the TSBP rules are in compliance with the OBRA 90 Medicaid requirements.

    2.4.1 Perform Prospective Drug User Review (DUR)

    At the time of dispensing a prescription drug order, the pharmacist must review the person’s medication record to identify:

    • Clinically significant drug-drug interactions
    • Therapeutic duplication
    • Drug-disease contraindication
    • Drug allergy interactions
    • Incorrect drug dosage or duration of drug treatment
    • Clinical abuse/misuse

    Upon identifying any clinically significant conditions, situations, or items listed above, the pharmacist shall take appropriate steps to avoid or resolve the problem including consultation with the prescribing provider.

    2.4.2 Medication Records

    The pharmacist must make a reasonable effort to obtain and record, in the person’s medication record, the following information on the person presenting a prescription:

    • Full name of the person for whom the drug is prescribed
    • Address and telephone number of the person
    • The person’s age and/or date of birth
    • The person’s gender
    • Any known allergies, drug reactions, idiosyncrasies, and chronic conditions or disease states of the person and the identity of any other drugs currently being used by that person may relate to prospective drug review.
    • Pharmacist's comments relevant to the person’s drug therapy, including any other information unique to the specific person or drug.
    • A list of all prescription drug orders dispensed (new and refill) to the person by the pharmacy during the last two years. Such list shall contain the following information:
      • Date dispensed
      • Name, strength, and quantity of the drug dispensed
      • Prescribing provider’s name
      • Unique identification number of the prescription
      • Name or initials of the dispensing pharmacists

    Individual medication records (profiles) must comply with and be maintained in compliance with TSBP regulations. The pharmacist may delegate the collection of the individual medication record to a technician. The pharmacist or designee is not required to obtain and record the person's information in a profile (medication record) if the person or his or her agent refuses to provide the necessary information for such individual medication records (profiles).

    2.4.3 Counseling

    The pharmacist is required to communicate to the person (or his or her agent) information concerning the dispensed prescription drug or device, including at a minimum the following:

    • The name and description of the drug
    • Dosage form, dosage, route of administration, and duration of drug therapy
    • Special directions and precautions for preparation, administration, and use by the person
    • Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur
    • Techniques for self-monitoring of drug therapy
    • Proper storage
    • Refill information
    • Action to be taken in the event of a missed dose

    The pharmacist is not required to provide consultation when the person (or his or her agent) refuses such consultation. The pharmacist shall document such refusal for consultation.

    TSBP rules require that written information accompany prescription drug orders be delivered to the person or a representative agent of that person.  Provision of written information must be in compliance with TSBP rules.

    Counseling requirements are to be in compliance with TSBP regulations. The counseling function must be performed by the pharmacist and cannot be delegated to a technician.