Drug Utilization Review (DUR) Program

The purpose of the Utah Medicaid DUR program is to promote evidence-based best clinical practice, as well as to identify patterns of fraud, abuse, gross overuse, and inappropriate or suboptimal treatment. We aim to partner with prescribers, pharmacists, and Medicaid patients to enhance prescribing and dispensing practices, as well as medication use by individual patients. Pharmacy staff utilize communication tools, such as motivational interviewing, and to promote and reinforce best practices in the delivery and administration of pharmacy benefits.

Prospective DUR

Prospective drug utilization review involves a review of drug therapy before each prescription is filled or delivered to a member and includes counseling of the member or their caregiver. This counseling involves motivational interviewing and is based on evidence-based predetermined clinical standards.

Retrospective DUR

Retrospective drug utilization interventions are often determined through a review of claims data or other records. Outcome measures are often derived from the Centers for Medicare and Medicaid Services (CMS) guidance, as well as measures outlined by the National Committee for Quality Assurance (NCQA) to best utilize claims data to create interventions and improve patient outcomes.

Current Drug Utilization Review Interventions

Stimulants are utilized first-line to treat ADHD. These agents have high misuse potential and are associated with significant, lasting adverse effects when taken at chronically high doses. Point-of-sale edits, as well as prior authorization requirements have been implemented based on guideline recommendations to minimize concurrent use of different stimulant medication classes and prevent utilization of unsafe chronic stimulant doses.

Antipsychotic (AP) medications can cause significant and sometimes irreversible metabolic and movement disorders. These side effects can be more pronounced in children than adults. Minimum DUR intervention requirements exist as a result of the SUPPORT Act (2018) which includes a program to monitor and manage the appropriate use of antipsychotic medications in children. Utah Medicaid requires prior authorization for claims outside of the FDA-labeled age limits and indications, as well as for claims with concurrent use of multiple antipsychotics in members under 18 years of age. Prior authorization requires documentation of guideline-recommended monitoring for metabolic and movement disorders, as well as additional clinical support for off-label and concurrent antipsychotic use. Pharmacists also perform peer-to-peer outreach with prescribers that are stratified by the number of patients receiving monitoring. Parents/guardians of children receiving Aps are also engaged via letter, encouraging them to ask their child's prescriber about testing and monitoring of movement disorders.

Adherence to hepatitis C antiviral medication therapy is essential for ensuring undetectable viral loads. Pharmacy staff telephonically reach out to patients who have been non-adherent to their Hepatitis C medications during a course of therapy and utilize motivational interviewing to identify barriers to adherence. Follow-up is conducted with non-adherent patients for the remainder of antiviral treatment.

The CDC and other public health organizations have outlined the risks for overuse and misuse of opioids and outline recommendations to reduce the risk of patient harm. Minimum DUR intervention requirements exist as a result of the SUPPORT Act (2018) which includes retrospective claims review for concurrent use of opioids in combination with other high-risk medications, including benzodiazepines and antipsychotics. Pharmacists telephonically reach out to providers of patients who are identified to be on concurrent benzodiazepine and opioid therapy and discuss CDC-recommended interventions to reduce the risk of harm, both generally in clinical practice and with individual patients. Discussions often include tapering opioid and benzodiazepine doses, utilizing other medications for anxiety, and ensuring naloxone dispensing and education.

The CDC and other public health organizations have outlined the risks for overuse and misuse of opioids and outline recommendations to reduce the risk of patient harm. Minimum DUR intervention requirements exist as a result of the SUPPORT Act (2018) which includes prospective DUR limits on days’ supply, fill quantities, therapeutic duplications, early refills, and maximum daily morphine equivalents (MED). Claims processed at the point-of-sale that exceed CDC-recommended limits on quantity limits, therapeutic duplications, and MED cannot be overridden at the pharmacy and require prior authorization to be considered for review.