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 For states’ convenience in filling out the DUR annual report, an NDC and drug category file [ZIP] extracted from the first quarter 2011 Medicaid drug product data file is provided.
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.
Below are the Medicaid DUR Annual reports for FFY 2010:
Questions on the Drug Utilization Review Program? Email DURPolicy@cms.hhs.gov.