Formulary Management & Drug Utilization Review (DUR)

What You Do Today

You manage the formulary: drug tier placement (generic, preferred brand, non-preferred, specialty), prior authorization criteria for non-formulary and high-cost drugs, step therapy protocols (try this cheaper drug first), quantity limits, and clinical exceptions. Prospective DUR runs at point of sale: checking for drug-drug interactions, therapeutic duplication, age/gender contraindications, and dose limits. Retrospective DUR analyzes utilization patterns across the population. P&T committee governance drives formulary decisions. Biosimilar management and specialty drug pipeline monitoring are increasing areas of focus.

AI Technologies

How It Works

ML analyzes drug utilization patterns across the population to identify outliers: prescribers with unusual prescribing patterns, members with poly-pharmacy risks, therapeutic categories with high waste (early discontinuation, switching patterns). NLP monitors clinical literature, FDA approvals, and safety communications to keep formulary decisions current with emerging evidence. ML-enhanced DUR adds risk scoring beyond standard interaction checking: predicting adverse event probability based on the patient's complete medication profile, diagnoses, lab values, and demographics rather than just pairwise drug interaction databases. Predictive models forecast specialty drug costs based on pipeline, utilization trends, and biosimilar adoption projections.