Utilization Control
Benefiting both acute and chronically injured workers, PMSI’s Utilization Control program manages access to medications, products and services by applying clinically based criteria to proactively evaluate medication or product appropriateness and cost effectiveness at point of service.
Prospective DUR
PMSI’s transactional controls work with common pharmacy adjudication Drug Utilization Review (DUR) edits to evaluate each prescription for inappropriate use associated with, but not limited to, therapy duplications, premature refills, and availability of a generic equivalent to ensure the medication is appropriate for the injury and compliant with the workers’ compensation-specific formulary. On average, 14.5% of medications are deemed non-compensable at point of service, preventing them from being dispensed—saving an average of $107 per prescription.
Workers’ Compensation Formulary
We created the industry’s first workers’ compensation-specific drug formulary. Designed to control costs and mitigate risk, the formulary ensures injured workers have access to the right medications based on the type and stage of injury. The formulary is approved by our Pharmacy and Therapeutics (P&T) Committee, which brings together the leading independent thinkers in the workers’ compensation field—from disciplines such as pharmacy, pain management, rehabilitation medicine and emergency medicine—to review PMSI’s clinical controls and discuss critical topics across the industry.
Catastrophic Care Support
Our highly qualified nurses evaluate the durable medical equipment and service needs of catastrophically injured workers while the patient is still in the hospital or acute care facility. They provide consultative advice and collaborate with the claims professional or case manager to help ensure that appropriate products and services are in place to facilitate a smooth transfer to the home environment.
Value to Our Clients
- Clinical oversight reduces inappropriate medication utilization resulting in risk reduction and cost savings
- Quicker access to appropriate medications for injured individuals
- Decreased administrative burden/reduced costs
- Specialized workers’ compensation offering contributes to customer satisfaction