Drug Utilization Review
Medicaid Drug Utilization Review (DUR) Program
The Medicaid Drug Utilization Review (DUR) Program promotes patient safety through state-administered utilization management tools and systems that interface with CMS’ Medicaid Management Information Systems (MMIS). Medicaid DUR is a two-phase process that is conducted by the Medicaid state agencies. In the first phase (prospective DUR) the state’s Medicaid agency’s electronic monitoring system screens prescription drug claims to identify problems such as therapeutic duplication, drug-disease contraindications, incorrect dosage or duration of treatment, drug allergy and clinical misuse or abuse. The second phase (retrospective DUR) involves ongoing and periodic examination of claims data to identify patterns of fraud, abuse, gross overuse, or medically unnecessary care and implements corrective action when needed.
On an annual basis, states are required to report on their state’s prescribing habits, cost savings generated from their DUR programs and their program’s operations, including adoption of new innovative DUR practices via the Medicaid Drug Utilization Review Annual Report Survey. On May19, 2014, CMS sent the Newly Revised Medicaid Drug Utilization Review Annual Report Survey [PDF] to each state. This new survey has an expanded Fraud, Waste and Abuse section, new questions in the Prescription Drug Monitoring Program section and questions regarding state Managed Care Organizations. For the states’ convenience in completing the FFY 2013 DUR annual report, an NDC and Drug Category file extracted from the first quarter 2014 Medicaid Drug product data file is provided. The previous version of the DUR survey may still be viewed at Medicaid Drug Utilization Review Annual Report Survey [PDF].
42 CFR Subpart K – Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims, Section 456.700-456.725, provides the requirements for the DUR program.
Medicaid Drug Utilization Review (DUR) Annual Reports
To view each State's Medicaid DUR Annual report, please visit the Medicaid Drug Programs Data and Resources page. The most recently posted annual reports are for FFY 2012.
The fee-for-service data from the FFY 2012 DUR reports has been compiled and presented in an improved format over last year by combining data from the two reports previously posted, the Comparison Report and the Summary Report into one Comparison/Summary Report. A Table of Contents has been added to the Comparison/ Summary Report to aid interested parties in reviewing the findings. A compilation of the 2012 Executive Summary Reports will be posted in the near future.
The fee for service FFY 2011 DUR reports have been presented in several sections to allow interested parties to see a comparison of the findings. The first section is a Comparison Report [ZIP], detailing state-by-state listing of each state’s response to the questions in the survey. The second section is a Summary Report [ZIP] of all states’ responses to individual questions. The third section is a compilation of the unedited Executive Summary Reports [PDF] submitted at the state’s option, depicting an overview of DUR activities during the FFY 2011.
2011 Drug Utilization Review (DUR) Innovative Practices
The Centers for Medicare and Medicaid Services (CMS) has reviewed the Innovative Practices that the states submitted in their 2011 DUR Annual Reports. In an effort to share useful information on the activities states are performing to improve the quality of care and prudent delivery of their programs. We have provided examples of those activities below. Please note that the examples provided do not reflect all the different approaches that states may be using as these were submitted at state option. The detailed descriptions of specific state programs were taken directly from the 2011 DUR reports submitted by the states. CMS did not edit the material submitted.
All state pharmacy programs have reported on various pre-authorization requirements. Some states reported specific practices, e.g., AK, AR, NC - increased oversight for specific drug therapies; FL, ME, NV - new electronic systems and protocols recently implemented to enhance their existing programs. For details please click on this link for Prior Authorization.
The misuse of antipsychotic drugs is prevalent throughout the country. Generally each state Medicaid pharmacy program is actively monitoring the prescribing of antipsychotic drugs with edits when the prescription is submitted to be filled, unless restricted by state law. We have highlighted the initiatives of CA, NV, PA, VA, and WV. For details please click on this link Antipsychotic Drug Monitoring.
The treatment of hemophilia is costly to all states. Utah has provided an example of how it reduces unnecessary waste and improved care by using case management control. For details please click on this link: Hemophilia Case Management.
All states have techniques to educate providers to improve the quality of their prescribing practices. California and Colorado shared their methods for disseminating educational information to prescribers in a timely fashion. For details please click on this link RetroDUR/Education.
Fraud, waste, misuse and abuse continues to be high priority for each state Medicaid program. States utilize a variety of tools to combat these issues including CT - Fraud Hotlines, MD - Corrective Case Management programs and DE, MT and, NJ - Chronic Pain Management. For details please click on this link Fraud, Waste, Abuse.
Please note: The information found at the links above were taken unedited from the 2011 DUR reports sent in by states. If you would like additional information about any of these programs, please contact the person listed in the contact information in the individual 2011 state report found at this link Medicaid Drug Programs Data and Resources.
Psychotropic Medication Use in Children in Foster Care
Much attention has been focused on monitoring the prescribing of psychotropic medications to children in foster care since the passage of the Child and Family Services Improvement and Innovation Act of 2011 (P.L.112-34). Children in state custody often have emotional and behavioral challenges as a result of maltreatment and trauma. Creating, coordinating and implementing monitoring protocols across various agencies (state child welfare, Medicaid and mental health systems) to ensure appropriate prescribing and monitoring of medication therapy requires careful planning. While there is no single way to create a perfect system, state DUR programs can develop and share effective strategies for building creative and collaborative methods for promoting quality care for these vulnerable individuals. To that end, we are providing a brief summary of different actions various states have taken to address this issue, along with a list of resources.
Questions on the Drug Utilization Review Program? Email DURPolicy@cms.hhs.gov.
Page last updated on June 18, 2014