Rational Drug Therapy Program  Program Information

The West Virginia University School of Pharmacy created the Rational Drug Therapy Program (RDTP) in 1995 for the Medicaid Program of the West Virginia Bureau for Medical Services (WVBMS) recipients.  The primary goal of the program is to promote the safe rational and cost effective use of drugs within the population served by the WVBMS.   A secondary goal of the WVU School of Pharmacy is to promote the concept of Pharmaceutical Care and its delivery to the patient served by the pharmacists in WV.

Pharmaceutical Care is defined by the American Pharmacy Association as a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient's other health care providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective. The goal of pharmaceutical care is to optimize the patient's health-related quality of life, and achieve positive clinical outcomes, within reasonable economic expenditures.

The federal law labeled as OBRA 90 requires each state to perform prospective and retrospective DUR Programs.  There must be implemented with the primary concern being the patient's outcome.  The laws' purpose of these DUR programs is to improve the quality of pharmaceutical care by ensuring that prescriptions are appropriate, medically necessary, and that they are not likely to result in adverse medical results Sec 1927 (g)(1)(A).  The law also states that the goal of the state's program must be to ensure appropriate drug therapy, while permitting sufficient professional prerogatives to allow for individualized drug therapy. (Sec 456.703).

The guidelines for the prospective drug utilization review performed by the RDTP are formulated by the Drug Utilization Review (DUR) Board of the WVBMS.  The goal of the board review high cost, high risk, and high use medications paid for by the WVBMS and to determine if management of payment of these agents can effect their usage and the outcomes of the recipients.  The guidelines set forth by this board are based on current literature review and the concepts of disease state management as well as cost containment.

After the DUR Board approves the guidelines, the WVBMS contacts their claims processor (Consultec Inc.) to not allow payment for the selected medications unless over-ridden by the RDTP.  The process involving the RDTP is therefore initiated after a pharmacy submits an online claim for payment for medication requiring prior authorization.  When the claim processor rejects payment for the claim the pharmacy is electronically notified to contact RDTP for prior approval.  The pharmacists can choose to initiate the RDTP process themselves, or notify the physician's office for them to initiate the process.  The pharmacist at this time always has the option to issue a seventy-two hour emergency prescription to prevent any negative outcome for the patient. The unpaid claim information with the patient and disease specific information is then phoned or faxed free of charge to the RDTP for their review. Email submission of forms is not permitted at this time due to the lack of confidentially of the internet.

The RDTP personnel review the submitted claim information against the DUR Board approved guidelines and can either approve payment for the claim, pend the claim for more information, or deny payment for the claim.  If a claim payment is denied, the prescribing physician always maintains the right and ability to appeal the RDTP decision to the Medical Director of the WVBMS.

Rational Drug Therapy Program  West Virginia University School of Pharmacy  P.O. Box 9511  Morgantown, WV 26506-9511  Phone 800 847 3859  Fax 800 531 7787