Understanding DUR Management

Workbook

Course 206055

Table of Contents
Introduction ................................................................................................................ 3
How are Drug Utilization Review (DUR) Warnings Generated? ................................. 4
Understand the DUR Engine ...................................................................................... 4
Hard Stop vs. Soft Stop .............................................................................................. 5
DUR Clinical Module Descriptions ............................................................................. 7
Third Party DUR and Prescriber DUR ...................................................................... 13
Workflow steps that affect DUR ............................................................................... 14
Other DUR Considerations....................................................................................... 15
Next Steps................................................................................................................ 16
Payroll ...................................................................................................................... 16
Appendix: Knowledge Check Answer Key .............................................................. 17

Understanding DUR Management: Workbook

Introduction
Drug Utilization Review (DUR) is a core clinical function that Pharmacists perform to
keep our patients safe and provide quality health care. When a prescription is
processed through RxConnect, the system checks for clinical alerts against several
DUR modules. As a Pharmacist, you are responsible for addressing all DUR warnings.
Upon completion of this course, you should be able to:

Identify the DUR Engines role in the process of managing DUR

Identify all of the modules that generate DUR alerts

You will learn the steps to complete final verification, including DUR verification, in the
Introduction to Quality Assurance Workstation web-based training (LEARNet #206050).
This training guide is provided in a self-paced format. Answers to each knowledge
check are in the appendix at the end of this workbook.
It will take you approximately 20 minutes to complete this workbook.

Understanding DUR Management: Workbook

How are Drug Utilization Review (DUR) Warnings Generated?

After all necessary information is entered for a prescription (including the User
Credentials of the team member completing data entry), the RxConnect system assigns
a number to the prescription. When adjudication is complete, this prescription is then
sent to the DUR Engine for centralized systemic evaluation.

Understand the DUR Engine

The DUR Engine is a computer process that compares the prescription being filled and
others on the patients profile (as well as conditions, allergies and patient age) against a
library of clinical data to generate warning alerts that Pharmacists can use at point of
care to complete a thorough DUR. The library of clinical data used at CVS retail
pharmacies is provided by First Data Bank (FDB).
A prescription is eligible for screening as soon as data entry and adjudication are
complete, including those pending final verification. The DUR Engine checks against a
number of modules, which will be described below. The information returned is shown
during the verification step of workflow.

Understanding DUR Management: Workbook

Hard Stop vs. Soft Stop

There are two different ways to display DUR warnings at verification in RxConnect:
Hard stops and soft stops. Hard stops are clinically significant alerts that are likely to
require action. Pharmacists must use their professional judgment to determine whether
to fill the prescription and document interventions. Soft stops are clinically significant,
but may not require intervention for all patients. DUR warnings are assigned to be hard
stops or soft stops by CVS/pharmacy based on the clinical module and/or severity.

Hard stop intervention codes can be entered into the system after ALL hard stops have
been viewed. The system allows the user to view soft stops before and after entering an
intervention code. The intervention codes available are:
A. Prescriber Consulted
B. Medication Review
C. Patient Consulted
Note: Hard stops can become soft stops on refills if no new DUR warnings are present. This
process is called FILTERING. When an alert is filtered, it will be noted on the screen with an
asterisk (*) and a statement.

Understanding DUR Management: Workbook

Knowledge Check
Circle the correct answer for each question below.
1. DUR Checks are performed on those prescriptions in a patients
profile that have been completed or are pending final verification.
a. True
b. False
2. Those prescriptions that result in a(n) ______ DUR warning require
a DUR Intervention Code.
a. Automatic DUR/Informational
b. Hard Stop
c. Soft Stop
d. Therapeutic DUR/Soft Stop

Understanding DUR Management: Workbook

DUR Clinical Module Descriptions

In the following pages, you will find a list of clinical modules, descriptions, and related
information to help you better understand DUR warnings at final verification.
Title

Title Statement

What does the

module check for?

What will the screen

display?

Drug-Drug
Interaction

The Drug-to-Drug
Interaction Module
(DDIM) identifies
clinically significant
drug-to-drug
interactions between
the prescription
being filled and
eligible prescriptions
in RxConnect and
for enterprise
patients, Caremark
Mail order and
Specialty Mail order.

Every drug fill is

checked against all
eligible prescriptions
in the patients central
profile, including
enterprise
prescriptions

The alert will show:

The FDB severity
level
The interacting
medication and
prescription details
A brief explanation of
the clinical effect

The database
covers every
product that is
approved for
marketing in the
United States. It
also covers many
commonly used
herbal and
nutritional products
available at CVS.

Geriatric
Precautions

The Geriatric
Precautions Module
identifies
medications that
cause increased risk
in patients over 65
years old.
The database
covers every
product that is
approved for
marketing in the
United States.

Eligible prescriptions
are determined by the
system, taking into
account factors like:
Fill date
Days supply
If there is another
prescription on the
profile for the same
drug
Some drugs will be
screened indefinitely
once on a patient
profile (for example,
nitroglycerin)
If a compound is
being dispensed, the
DUR Engine will
check drug
interaction codes for
each individual
ingredient

Every fill dispensed

checks if the patient is
over 65 years old
against the NDC that
will be dispensed for
geriatric precautions.

*Note You can

access the full
monograph by selecting
M in the navigation
bar.

The alert will show:

The FDB severity
level
Drug being filled and
specific agent of
concern
A brief explanation of
the clinical effect
Physiological system
affected

How should a Pharmacist

address the DUR warning?
Severity Level 1
interactions are
contraindicated drug
combinations. They require
RPh professional judgment
to fill, prescriber
authorization and
documentation
Severity Level 2
interactions are severe
interactions. Pharmacists
should exercise
professional judgment and
review the profile/contact
the patient/ consult the
physician as required
Severity Level 3
interactions are moderate
interactions. Pharmacists
should exercise
professional judgment and
review the profile/contact
the patient/ consult the
physician as required
Severity Level 9 is of
unknown potential or
between prescription and
herbal products.
Pharmacists should
assess the risk and act as
needed
Severity Level 1 alerts are
contraindications in
geriatric patients. They
require RPh professional
judgment to fill, prescriber
authorization and
documentation
Severity Level 2 alerts
indicate precautions.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required

Understanding DUR Management: Workbook

Title

Title Statement

What does the

module check for?

What will the screen

display?

Drug
Condition
Alerts

The Drug-Condition
Contraindications
Module identifies
clinically significant
drug-condition
interactions.

Every fill dispensed

NDC is checked
against the conditions
coded in the patient
profile. Conditions are
entered in the profile
by ICD code, but have
clinical tags on them
called DXIDs. FDB will
trigger an alert if an
NDC and DXID have a
clinical interaction. ICD
codes can have one,
many or no DXIDs tied
to them, which is
determined by FDB.

The alert will show:

The FDB severity
level
Drug being filled and
specific agent of
concern
ICD code, condition
description, and date
entered
A brief explanation of
the clinical effect

Severity Level 1
interactions are absolute
contraindications. They
require RPh professional
judgment to fill, prescriber
authorization and
documentation
Severity Level 2
interactions are relative
contraindications.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required
Severity Level 3
interactions are warnings.
Pharmacists should
assess the risk and act as
needed

Every fill dispensed

NDC is checked
against the allergies
coded in the patient
profile. Allergies are
entered in the profile
by ingredient, drug, or
drug class using a
unique FDB coding
system.

The alert will show:

Drug being filled and
specific agent of
concern
Allergy code, type of
allergy, and date
entered
A brief explanation of
the clinical effect
Reported allergy
symptoms and allergy
notes

These alerts do not have

severity levels, but may
require RPh professional
judgment to fill, prescriber
authorization and
documentation.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required

The database
covers every
product that is
approved for
marketing in the
United States.

Drug
Allergy
Alerts

The Drug Allergy

Module identifies
clinically significant
interactions between
active drug
ingredients and the
patient allergy
codes.
The database
covers every
product that is
approved for
marketing in the
United States.

Although active and

inactive ingredient
allergies can be coded
in the system, the
allergy module only
checks ACTIVE
ingredients.

How should a Pharmacist

address the DUR warning?

Understanding DUR Management: Workbook

Title

Title Statement

What does the

module check for?

What will the screen

display?

Duplicate
Therapy

The Duplicate
Therapy Module
identifies
medications with
overlapping
therapeutic or
pharmacological
uses that can create
added toxic effect,
adverse events or
therapeutic
redundancy without
benefit for the
prescription being
filled and eligible
prescriptions in
RxConnect and for
enterprise patients,
Caremark Mail order
and Specialty Mail
order.

Every fill dispensed

NDC is checked
against all eligible
prescriptions in the
patient central profile,
including enterprise
prescriptions

The alert will show:

Drug being filled
Interacting
prescriptions,
including the
medication names

The database
covers every
product that is
approved for
marketing in the
United States.

Eligible prescriptions
are determined by the
system, taking into
account factors like:
Only systemic
drugs are
considered for
duplicate therapy
Fill date
Days supply
If there is another
prescription on the
profile for the same
drug

How should a Pharmacist

address the DUR warning?
These alerts do not have
severity levels, but may
require RPh professional
judgment to fill, prescriber
authorization and
documentation.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required

*Note Some
therapeutic classes
have thresholds that
must be met before
duplicate therapy will
trigger. For example, a
patient must be on
more than 2
anticonvulsants for the
system to warn
against duplicate
therapy.

Understanding DUR Management: Workbook

Title

Title Statement

What does the

module check for?

What will the screen

display?

Minimum /
Maximum
Dosing

The Min/Max Dosing

Module checks the
appropriateness of
the total daily dose
for drugs that have
established dosing
schedules.

Every fill dispensed

NDC is checked to see
if there is a dosing
schedule and if the
patient is being
provided a total daily
dose within that
range.

The alert will show:

Drug being filled
Graphic with
Dispensed total daily
dose, Recommended
min/max daily dose
and the % over or
under

The database
covers every
product that is
approved for
marketing in the
United States.

Total Daily Dose is

calculated by data
entered quantity
divided by days
supply.

How should a Pharmacist

address the DUR warning?
These alerts do not have
severity levels, but may
require RPh professional
judgment to fill, prescriber
authorization and
documentation.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required

Dosing is split into the

following age bands:
Pediatric 31 days
to 14 years old
Adult 15 years to
64 years old
Geriatric 65+
years old
Infants below 31
days old or when
no dosing available
specific hard stop
alerting you no
dosing is available
*Note Pediatric
dosing is mostly
weight based, using
th
th
the 5 and 95 weight
percentile to calculate
an acceptable min and
max range. Adult and
geriatric weight-based
drugs will not run
DUR, but will return an
alert telling you to
perform manual DUR.

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Understanding DUR Management: Workbook

Title

Title Statement

What does the

module check for?

What will the screen

display?

Pediatric
Precautions

The Pediatric
Precautions Module
identifies
medications that
cause increased risk
in patients under 15
years old.

The system checks if

the patient is under 15
years old against the
NDC that will be
dispensed for pediatric
precautions.

The alert will show:

The FDB severity
level
Drug being filled and
specific agent of
concern
A brief explanation of
the clinical effect
Physiological system
affected

Severity Level 1 alerts are

contraindications in
pediatric patients. They
require RPh professional
judgment to fill, prescriber
authorization and
documentation
Severity Level 2 alerts
indicate relative
contraindications.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required
Severity Level 3 alerts
indicate no studies have
been done, but warning
exist. Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required

The alert will show:

Drug being filled and
specific agent of
concern
Pregnancy Category
A brief explanation of
the clinical effect
Reason for alert
(whether reported
pregnant or
childbearing age
caution)

If reported pregnant:
o Category X - The drug
SHOULD NOT BE
DISPENSED.
Pharmacists must notify
the physician.
o Category D or Severity
1- requires RPh
professional judgment to
fill, prescriber
authorization and
documentation
o Category C or Severity 2
- Pharmacists should
exercise professional
judgment and review the
profile/contact the
patient/ consult the
physician as required
If childbearing age:
o Pharmacists should
determine pregnancy
status and update in
RxConnect. Pharmacists
should exercise
professional judgment
and review the
profile/contact the
patient/ consult the
physician as required

The database
covers every
product that is
approved for
marketing in the
United States.

Pregnancy
Precautions

The Pregnancy
Precautions Module
identifies
medications that
cause increased risk
in patients reported
as pregnant, or
those of
childbearing age.
The database
covers every
product that is
approved for
marketing in the
United States.

Some alerts only apply

to a specific age
segment of pediatric
patients. In these
cases, alerts will only
appear based on the
patient age. For
example, a 13 year old
patient will not receive
an alert for
dextromethorphan,
which is
contraindicated in
patients younger than
6.

The system checks if

the patient is:
Female
Pregnant (via ICD
code or pregnancy
patient indicator)
Of childbearing age
(15-45 years old)
The system checks if
the drug is:
FDA Category C, D,
or X
First Data Bank
Category 1 or 2 (if
no FDA category
exists or FDB
severity override)

How should a Pharmacist

address the DUR warning?

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Understanding DUR Management: Workbook

Title

Title Statement

What does the

module check for?

What will the screen

display?

Lactation
Precautions

The Lactation
Precautions Module
identifies
medications that
cause increased risk
in patients reported
as breastfeeding, or
those of
breastfeeding age.

Every fill dispensed

checks if the patient is:
Female
Breastfeeding (via
ICD code or lactation
patient indicator)
Of breastfeeding age
(15-45 years old)

The alert will show:

Drug being filled and
specific agent of
concern
If excreted in milk and
effect on infant
A brief explanation of
the clinical effect
Reason for alert
(whether reported
breastfeeding or
breastfeeding age
caution)

The database
covers every
product that is
approved for
marketing in the
United States

How should a Pharmacist

address the DUR warning?
Severity Level 1 alerts are
contraindications. They
require RPh professional
judgment to fill, prescriber
authorization and
documentation
Severity Level 2 alerts
indicate precaution.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required
Severity Level 3 alerts
indicate no known risk
have been done, but
warning exist. Pharmacists
should exercise
professional judgment and
review the profile/contact
the patient/ consult the
physician as required

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Understanding DUR Management: Workbook

Title

Title Statement

What does the

module check for?

What will the screen

display?

Inferred
Condition

The Inferred
Condition Module
identifies clinically
significant drugcondition
interactions by
inferring conditions
based on drugs that
the patient is taking.

Every fill dispensed

NDC is checked
against the conditions
that are inferred by the
system. The system
infers medical
conditions by first
identifying eligible
prescriptions. Then the
system will look at
what indications the
medication is used for.
An alert will only be
generated for drugs
that strongly infer a
specific condition (for
example, metformin
for diabetes).

The alert will show:

Drug being filled and
specific agent of
concern
Inferred condition
description, and date
entered
A brief explanation of
the clinical effect

Eligible prescriptions
are determined by the
system, taking into
account factors like:
Fill date
Days supply
If there is another
prescription on the
profile for the same
drug

How should a Pharmacist

address the DUR warning?
Severity Level 1
interactions are absolute
contraindications. They
require RPh professional
judgment to fill, prescriber
authorization and
documentation
Severity Level 2
interactions are relative
contraindications.
Pharmacists should
exercise professional
judgment and review the
profile/contact the patient/
consult the physician as
required
Severity Level 3
interactions are warnings.
Pharmacists should
assess the risk and act as
needed

*Note Limited
conditions will be
inferred from
medications during a
pilot phase of the
module.

Third Party DUR and Prescriber DUR

Third Party Processors frequently provide Patient-Specific information to help the DUR
decision process. Additionally, Electronic Medical Records and Electronic Health
Records have the capability to send DUR warnings along with electronic prescriptions.
RxConnect will set these alerts as hard stops and soft stops based on type and clinical
severity.

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Understanding DUR Management: Workbook

Workflow steps that affect DUR

Please note the following information and share with colleagues to ensure specific care
is taken when entering the following information, as it directly impacts how DUR runs
and the quality of clinical information available to you at point of care:
Data Entered
into RxConnect

DUR Module

Dispensed
Quantity &
Day Supply

Minimum &
Maximum
Dosing

Allergy
Symptoms and
Notes

Drug Allergy
Module

OPTIMIZING DUR

Example

How? Correctly enter

dispensed quantity and day
supply

Rx: Fluticasone 50 mcg nasal

spray
SIG: 1 spray in each nostril
daily
Quantity: 16 gm

Why? Dispensed quantity and

day supply are used to calculate
a patients total daily dose (TDD).
The TTD will then determine if the
dose exceeds the minimum or
maximum dose.

If day supply is entered as 30

instead of 60, the Min/Max
Dosing module will alert the
RPh based on TWICE the
prescribed daily dose.

How? Document a patients

allergy with the associated
symptom(s) and other allergy
notes

Rx: Augmentin 875 mg/125 mg

Previous Allergy Reported:
Amoxicillin (symptoms:
diarrhea & upset stomach)

Why? Obtaining accurate

allergy information ensures that
each prescription is screened, to
avoid a known allergic reaction.
Allergy information is visible to
pharmacy teams throughout the
Enterprise.

Capturing complete allergy

information, including
associated symptom(s), allows
the RPh to be better prepared
when counseling that patient.
Antibiotics often cause stomach
upset, and through patient
counseling, a prescriber call is
usually unnecessary.

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Understanding DUR Management: Workbook

Data Entered
into RxConnect

DUR Module

OPTIMIZING DUR

Example

Pregnancy
Status
&
Due Date

Pregnancy
Precautions

How? Enter pregnancy status

with expected due date in the
patients Reported Health Status
fields

Jamie informs the Technician

that she is pregnant with a due
date of 12/25/15. The
Technician documents the
pregnancy status and due date
which then instructs the
pregnancy module to prompt
the RPh with any available
medication alerts.

Why? The system will alert the

RPh if a potentially dangerous
drug is being dispensed to a
pregnant patient. Once the due
date has passed, RxConnect will
prompt the RPh to update the
pregnancy status in an effort to
reduce system prompts in the
future.

Lactation
Status

Lactation
Precautions

How? Enter lactation status in

the patients Reported Health
Status field

Why? Some medications are

excreted through breast milk and
can potentially reach the child.
The system will alert the RPh if a
potentially dangerous drug is
being dispensed to a patient that
is nursing.

Linda informs a pharmacy team

member that she has begun
breast feeding. The pharmacy
team member documents the
patients lactation status which
instructs the lactation module to
prompt the RPh with any
available medication alerts.

Other DUR Considerations

Compounds will run all modules of DUR except dosing

Nasal and ophthalmic medications have 25% buffer above the high dose and
below the low dose to avoid over messaging

Key Training Takeaway

RxConnect will provide DUR warnings to Pharmacists at the point of care based on
patient profiles and the information that pharmacy teams enter into the system.

Course Completion
Congratulations! You have completed the Understanding DUR Management workbook.
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Understanding DUR Management: Workbook

If you have any additional questions regarding what you have learned in this course,
contact your Pharmacy Supervisor or Trainer to discuss.

Next Steps
In order to receive credit for the completion of this workbook, you need to complete an
on-line assessment to test your understanding of what you have learned. This
assessment is available from the Understanding DUR Management course description
page on LEARNet. Please contact your Trainer with any questions/concerns.

Payroll
In order to be paid properly for completing this workbook and assessment, your time for
completing this training should be submitted on your Weekly Pharmacist Payroll Sheet as
part of regular operating hours.
*Include time spent reading the workbook and completing the on-line
assessment.

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Understanding DUR Management: Workbook

Appendix: Knowledge Check Answer Key

The following provide answers to the knowledge check questions from this course.
Circle the correct answer for each question below.
1. DUR Checks are performed on prescriptions that include those in
a patients profile that have been data entered or are pending final
verification.
a. True
b. False
2. Those prescriptions that result in a(n) ______ DUR Event require
a DUR Intervention Code.
a. Automatic DUR/Informational
b. Critical DUR/Hard Stop
c. Informational/Soft Stop
d. Therapeutic DUR/Soft Stop

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