Drug utilization review is the process a health plan, pharmacy program, or related administrator uses to check whether prescription drug use is safe, appropriate, and consistent with benefit rules. In plain language, it is the review that looks for duplicate therapy, unsafe combinations, excessive use, or other pharmacy-claim issues before or after payment.
How DUR works
Drug utilization review can occur at different stages:
- prospective review before the prescription is filled
- concurrent review while treatment is ongoing
- retrospective review after claims have already been paid
The review may look at dosage, refill timing, therapeutic duplication, drug interactions, age-related concerns, and whether the prescription fits the plan’s authorization rules.
Why it matters to insurers
Insurers and health plans use DUR to control both clinical risk and claim cost. Effective review can:
- reduce unsafe prescribing patterns
- flag fraud, waste, or overutilization
- support formulary compliance
- improve consistency in pharmacy claims handling
Because pharmacy benefits combine medical judgment and cost management, DUR is a core insurance-operations tool rather than just a clerical check.
Practical example
A member tries to fill two drugs from the same therapeutic class within a short period. The pharmacy system flags the claim for drug utilization review. The plan may require clarification from the prescriber before authorizing payment, depending on the medication and the plan rules.
Related Terms
- Drug Formulary
- Drug Price Review
- Pharmacy and Therapeutics Committee
- Major Medical Insurance
- Health Maintenance Organization