Drug Utilization Review Program. (A) The Contractor shall operate a Drug Utilization Review (DUR) program that includes prospective drug review, retrospective drug use review, and an educational program as required at 42 CFR 456, subpart K.
(B) The Contractor shall provide a detailed description of its DUR program activities to the Department on an annual basis, as directed by the Department.
Drug Utilization Review Program. The MCO must have a process in place to conduct prospective and retrospective utilization review of prescriptions that is consistent with Medicare Part D drug utilization review standards (see 42 C.F.R. 423.153). Prospective review should take place at the dispensing pharmacy’s point-of-sale (POS). The prospective review at the POS should compare the prescribed medication against previous drug history for drug-to-drug, ingredient duplication, therapeutic duplication, and high dose situations. The MCO’s retrospective review should monitor prescriber and contracted pharmacies for outlier activities. Retrospective reviews should also determine whether services were delivered as prescribed and consistent with the MCO’s payment policies and procedures. Prior to the Operational Start Date, HHSC will transmit a file with up to one year of medication history for Members with recent Medicaid eligibility, moving from the fee-for-service program. Outgoing MCOs will transfer this data for members moving to a new MCO.
Drug Utilization Review Program. The MCO must have a process in place to conduct prospective and retrospective utilization review of prescriptions that is consistent with Medicare Part D drug utilization review standards (see 42 C.F.R. § 423.153). Prospective review should take place at the dispensing pharmacy’s point-of-sale (POS). The prospective review at the POS should compare the prescribed medication against previous drug history for drug-to-drug, interactions, ingredient duplication, therapeutic duplication, age or gender contraindications, drug-allergy contraindications, overutilization or underutilization, incorrect dosage, and high dose situations. The MCO’s retrospective review should monitor prescriber and contracted pharmacies for outlier activities. Retrospective reviews should also determine whether services were delivered as prescribed and consistent with the MCO’s payment policies and procedures. The MCO must provide a summary of the quarterly retrospective reviews, including outcomes, as described in UMCM Chapter 5.13.1, MCO Drug Utilization Review (DUR) Quarterly Report Template. The MCO’s Drug Utilization Review should specifically assess prescribing patterns for psychotropic medications as defined by Texas Family Code § 266.001(7). If the MCO identifies patterns outside of the MCO’s parameters for psychotropic medications, or if HHSC notifies the MCO of outlier prescribing patterns, then the MCO must conduct a peer-to-peer discussion on the appropriateness of the drug regimen with the prescriber. For children, the MCO must model its parameters on DFPS’s Psychotropic Medication Utilization Parameters for Xxxxxx Children. (See DFPS’s website for more information: xxxx://xxx.xxxx.xxxxx.xx.xx/Child_Protection/Medical_Services/guide-psychotropic.asp).For adults, the MCO must base its parameters for psychotropic medications on approved compendia, such as peer-reviewed academic literature or nationally accepted guidelines.
Drug Utilization Review Program. The MCO must have a process in place to conduct prospective and retrospective utilization review of prescriptions that is consistent with Medicare Part D drug utilization review standards (see 42 C.F.R. § 423.153). Prospective review should take place at the dispensing pharmacy's point-of-sale (POS). The prospective review at the POS should compare the prescribed medication against previous drug history for drug-to-drug, interactions, ingredient duplication, therapeutic duplication, age or gender contraindications, drug-allergy contraindications, overutilization or underutilization, incorrect dosage, and high dose situations. The MCO's retrospective review should monitor prescriber and contracted pharmacies for outlier activities. Retrospective reviews should also determine whether services were delivered as prescribed and consistent with the MCO's payment policies and procedures. The MCO must provide a summary of the quarterly retrospective reviews, including outcomes, as described in UMCM Chapter 5.13.1, "MCO Drug Utilization Review (DUR) Quarterly Report Template." Prior to the Operational Start Date, HHSC will transmit a file with up to one year of medication history for Members with recent Medicaid eligibility, moving from the fee-for-service program. Outgoing MCOs will transfer this data for members moving to a new MCO.
Drug Utilization Review Program. The CONTRACTOR shall maintain written policies and procedures governing its drug utilization review (DUR) program, in compliance with any applicable Federal Medicaid law.
