Common use of Drug Utilization Review Program Clause in Contracts

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 drug utilization review program (DUR) process in place to conduct prospective and retrospective utilization review of prescriptions prescriptions. The MCO's DUR program must comply with 42 U.S.C. § 1396r−8 and 42 CFR part 456, subpart K. The MCO must submit an annual report to HHSC Vendor Drug Program (VDP) that is consistent with Medicare Part D drug utilization review standards (see provides a detailed description of its DUR program activities, as provided for under 42 C.F.R. CFR § 423.153438.3(s). Prospective review should take place at the dispensing pharmacy’s point-of-sale point−of−sale (POS). The prospective review at the POS should compare the prescribed medication against previous must include screening to identify potential drug history for drug-to-drug, interactions, ingredient duplicationtherapy problems such as drug− disease contraindication, therapeutic duplication, age or gender contraindications, drug-allergy contraindications, overutilization or underutilizationadverse drug−drug interaction, incorrect drug dosage, incorrect duration of drug treatment, drug−allergy interactions, and high dose situationsclinical abuseƒmisuse. The MCO’s retrospective review should must monitor prescriber and contracted pharmacies for outlier activities. Retrospective reviews should must 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 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 http:ƒƒwww.dfps.state.tx.usƒChild ProtectionƒMedical Servicesƒguide−psychotropic.asp). For adults, the MCO must base its parameters for psychotropic medications on approved compendiaa peer−reviewed, industry standard such as peer-reviewed academic literature the DSHS Psychotropic Drug Formulary at http:ƒƒwww.dshs.state.tx.usƒmhprogramsƒFormulary.shtm. The DSHS Psychotropic Drug Formulary provides tables summarizing the recommended dosage ranges for psychotropic drugs for children, adolescents, and adults. These dosage ranges are guidelines and are not intended to replace other references or nationally accepted guidelinesthe clinician's clinical judgment.