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Quality Assurance Policies & Procedures

KelseyCare Advantage’s Quality Assurance Processes are designed to help ensure the safety and effectiveness of care related to prescription drugs. These Processes focus on preventing medication errors, avoiding adverse drug events or interactions, and optimizing medication use. Some of our most important Quality Assurance Processes are described below.

Drug Utilization Review

There are two types of drug utilization review: concurrent and retrospective. Concurrent Drug Utilization Review (“DUR”) checks are intended to screen for potential safety issues (including the examples in the bulleted list below) before you receive your prescription, and is performed before or at the same time that the prescription is dispensed, typically at the pharmacy. Retrospective Drug Utilization Review (“RDUR”) is a review of your prescription drug that is performed on a regular basis, analyzing our computerized prescription data and other records to help identify and avoid potential medication issues. If our review identifies any such issues, we will work with your physician to correct the problem. Examples of the potential medication issues our DUR and RDUR programs are designed to detect and prevent include the following:

  • Unnecessarily taking more than one drug to treat the same medical condition
  • Drugs that may not be appropriate because of your age or gender
  • Taking too much or too little of a certain drug
  • Potentially harmful interactions between two drugs you are taking
  • Incorrect drug dosage
  • Allergic reactions to drugs
  • Taking a drug for an inappropriate reason or in an incorrect manner
Utilization Management (“UM”)

KelseyCare’s UM rules aim to encourage appropriate and cost-effective use of Part D prescriptions by placing additional requirements or limits on the coverage of certain medications. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples include Prior Authorization, Quantity Limits, Step Therapy, and substituting generic drugs for brand name drugs when possible. You can learn more about these tools by visiting our Glossary page.

Medication Error Identification and Reduction (MEIR)

Our MEIR process is designed to identify and address internal medication errors, such as being given the wrong drug by a pharmacist or the wrong dose frequency being printed on the prescription bottle’s label. These are generally errors with the dispensing of a prescription as opposed to an issue with the doctor writing that prescription in the first place, and are issues that cannot be detected by DUR and RDUR. We conduct ongoing reviews to identify these errors, but members may also report these types of errors.

Medication Therapy Management (“MTM”)

To learn about our Medication Therapy Management (“MTM”) program, please visit our dedicated MTM page.