Managed Care Organization (MCO) Request for Drug Utilization Review (DUR) Injured worker last name, first name Claim number Allowed conditions Date of injury Reference claims // MCO name Telephone number MCO physician/nurse signature Email address MCO physician/nurse name requesting DUR (Print) Fax number Date // Reason for request A Select at least one criteria A validated opiate trending report that shows a 25 percent or greater increase in monthly morphine equivalent dose (MED) Opiate trending report claims between six and 24 months only with a daily MED 60-120mg Opiate trending report claims more than 25 months old with a daily MED > 120mg A claim with an MED of 60mg/day or greater, plus diazepine equivalent dose of 20mg/day A claim with an MED of 60mg/day or greater, plus two anxiolytics or an anxiolytic, plus hypnotic A claim with a medication(s) restarted after a six-month hiatus in prescription coverage Drug, dose, duration of therapy is not consistent with official disability guidelines or other published clinical standard. (Standard used for selection must be cited.) A claim where aberrant findings are discovered in a urine drug screen, (e.g., illegal substances, non-prescribed controlled substances or the absence of prescribed drugs) Insufficient or no medical documentation of treatment by a prescribing physician in the past 12 months Verbally indicated by prescriber but not provided in writing B Select the appropriate reason The employer or third-party administrator has requested a claim for a DUR that does not meet the criteria in Section A. The MCO medical director has reviewed the claim and requests a DUR based on the information provided below. C Immediate discontinuance of coverage Written statement by prescriber received Date MCO medical director signature // Cite supporting documentation imaged in the claim, or list and attach additional information. Do not separate supporting documentation. BWC-3934 (Rev. April 24, 2017) MEDCO-34 American LegalNet, Inc. www.FormsWorkFlow.com Managed Care Organization (MCO) Request for Drug Utilization Review (DUR) Medication physician reviewer instructions Review the claim file. In the Analysis section, indicate the medical records reviewed, specifically referencing important information from those records. Provide an opinion based upon the information identified in the Analysis section. Explain your opinion, within a reasonable degree of medical certainty, referencing, where appropriate, Ohio State Medical Board Guidelines, Official Disability Guidelines and the standard of care for the community. Relate this information to the specifics of this case, i.e., allowed conditions and/or focus of treatment. Therapeutic group code description Drug name, strength Recommend medication reimbursement approved Recommend medication reimbursement denied Therapeutic group code Total weighted MED/day (Morphine equivalent dose) Comments Total weighted AED/day (Anxiolytic equivalent dose) BWC-3934 (Rev. April 24, 2017) MEDCO-34 American LegalNet, Inc. www.FormsWorkFlow.com Managed Care Organization (MCO) Request for Drug Utilization Review (DUR) 1. For each therapeutic drug group, please answer the following: a. Is the group reasonably related to the treatment of the allowed conditions? b. Is the group reasonably necessary for the treatment of the allowed conditions? c. Is the cost of the group medically reasonable for the treatment of the allowed conditions, i.e., is the use of this group appropriate resource utilization? 2. For each specific drug, including its prescribed dosage and duration, please answer the following: a. Is the drug, as prescribed, reasonably related to the treatment of the allowed conditions? b. Is the drug, as prescribed, reasonably necessary for the treatment of the allowed conditions? c. Is the cost of the drug, as prescribed, medically reasonable, for the treatment of the allowed conditions, i.e., is the drug, as prescribed, appropriate resource utilization? 3. With the understanding that all drugs are potentially harmful, please answer the following: a. Does the potential harm of any of the prescribed drugs in the amounts currently prescribed substantially outweigh the expected medical benefit of the drug? b. If yes, is there a medically supported alternative medication for treatment of the allowed condition? c. Is the combination of currently prescribed drugs in compliance with best practices? Physician's narrative Analysis Physician's name (typed) Physician's signature Date Time spent // BWC-3934 (Rev. April 24, 2017) MEDCO-34 American LegalNet, Inc. www.FormsWorkFlow.com