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Mountain-Pacific contracts with both Medicare and Medicaid to provide quality improvement activities surrounding the delivery of pharmacy services to beneficiaries and recipients. Medicare activities are related to the prescription drug coverage provided by stand-alone drug plans and Medicare Advantage plans through the Part D benefit. Medicaid activities are based on concurrent and retrospective review of medication usage in Medicaid programs. This Medicaid review includes pharmacy claims data, criteria development and application through prior authorization and evidence-based review for preferred drug lists.
Drug Utilization Review - Mountain-Pacific administers the Drug Use Review Program, the Drug Prior Authorization Program and the Pharmacy Case Management Program for Montana Medicaid. These programs all coordinate efforts to ensure optimum patient care while implementing retrospective drug use review, educational interventions, and limited evaluations of prescription drug choices, and while decreasing potentially harmful effects of medication use.
The Drug Utilization Review (DUR) board consists of ten members. These members are licensed and actively practicing physicians and pharmacists whose main focus is retrospective review and analysis of claims-based data to identify patterns of fraud, abuse, gross overuse, or inappropriate or unnecessary care. In addition, the DUR board evaluates therapeutic classes using evidence-based medicine principles for inclusion in the preferred drug list. Finally, the DUR board makes recommendations to Montana Medicaid about management of the pharmacy benefit.
Case Management - The goal of this program is to exchange information with providers about drug therapy and patient-specific drug usage in a nonbiased manner. Mountain-Pacific’s access to the medical and pharmacy services the patient is currently receiving proves useful to providers in caring for patients by allowing for the identification of multiple providers, multiple pharmacies and duplicative drug regimens.
Drug Prior Authorization - The Drug Prior Authorization Unit administers the prior authorization components of the Prescription Drug Program, Home Infusion Therapy Program, and the Mental Health Service Program. It consists of a team of pharmacists and pharmacy technicians which uses a preferred drug list as well as criteria from evidence-based guidelines provided by the DUR board and the Department of Public Health and Human Services to authorize payment of selected medications and/or professional service fees.
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