Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx (PDP) Members
Policies and Procedures
Quality assurance policies and procedures
How is Quality Assurance defined?
Quality Assurance includes the processes and systems put in place to evaluate prescriptions for health and safety issues. They help promote the appropriate use of medications by improving compliance and reducing medication errors and adverse drug interactions.
Quality Assurance programs
Quality assurance processes for Blue Medicare HMO and Blue Medicare PPO are summarized below:
- Concurrent Drug Utilization Review (DUR): this occurs while a claim is being processed at the pharmacy. Prescriptions are screened for the following safety issues and the pharmacist is sent a message immediately, alerting them of the potential issue.
- Drug Interactions: Instances when the prescribed drug can potentially result in ineffective or unsafe treatment when used in combination with another drug
- Drug-Allergy: Identifies when the prescribed drug may potentially cause problems based on patient's reported allergies.
- Drug-Disease: Instances when the prescribed drug may potentially worsen the patient's reported medical condition(s).
- Drug-Gender Contraindications: Identifies prescription medications being inappropriately filled based on patient gender.
- Drug-Age: Identifies those drugs that are contraindicated for use by older adults.
- Excessive Daily Dosing and Duration of Therapy: Identifies when a prescription claim is being filled for more than the recommended maximum daily dose or duration.
- Refill Too Soon or Too Late: Identifies patients who may not be taking their medication as prescribed by their physician.
- Therapy Duplication: Identifies when the prescription being filled is from the same Therapeutic Class as other medications in the members profile.
- Potential Drug Name Confusion: Identifies prescriptions that sound alike, or when written, look alike.
- Retrospective Drug Utilization Review (DUR): this occurs after the prescription has been dispensed. It is a program that evaluates a members' drug history to identify prescribing issues. Alerts are provided by mail to physicians, addressing prescribing practices and uses that are unsafe, ineffective, or otherwise inconsistent with evidence-based standards of care. Retrospective DUR complements the Concurrent DUR program by identifying physicians who for some reason may be resistant to the messages generated by concurrent monitoring.
The Retrospective DUR health and safety alerts are made up of four key categories:
- Potential Drug-Drug Interactions: Instances when prescribed medications can potentially result in ineffective or unsafe treatment when used in combination with another drug
- Dose Considerations with Pain Medications: Examines the use of certain high dose pain medications
- Drug Age Considerations: Considers the adverse effects of certain drugs or drug classes on the elderly population.
- Therapy Duplication: Identifies the use of two or more drugs in the same therapeutic class that may put the patient at risk of additional unwanted side effects or adverse medical event.
- Refill Reminders to Patients: As part of the dispensing process, a refill notice is generated by computer and included with each dispensed mail-order prescription. The email refill reminder program is designed to remind plan members to refill and continue to take important medications, specifically those medications that are for chronic conditions for which there may not always be signs and symptoms of illness.
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Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC does not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association.
The information on this page is current as of 10/01/2009.