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Drug Utilization Review Requirements

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Sacramento
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

The health plan and entities delegated to fill prescriptions for outpatient drugs (“applicable entities”) must:

  • Operate a drug utilization review (DUR) program.1
  • Submit the following to the Department of Health Care Services (DHCS):
    • Updated policies and procedures that address each of the requirements detailed below.
    • Annual DUR Report.

Requirements for the DUR program

The requirements include the topics listed below.

  • Safety edits, including early, duplicate and quantity limits
    Describe the opioid-related prospective safety edits, as well as the automated process for retrospective claims review that the health plan or the applicable entity has in place to address: duplicate fill, early fill and quantity limits. The health plan and applicable entities must not allow refills earlier than 75% of the time when the previous fill should be exhausted; duplication of the same service on the same date of fill; and the provision of acute medications in excess of a 30-day supply, or for chronic medications, a 90-day supply without prior authorization approval.
  • Maximum daily morphine milligram equivalents (MME) safety edits
    1. Describe the prospective safety edits for the maximum MME/daily that can be prescribed to a member enrolled for treatment of chronic pain, not to exceed 500 MME/daily without prior authorization. This safety edit must include a MME/daily threshold amount to assist in identifying members at potentially high-clinical risk who may benefit from closer monitoring and care coordination.
    2. Describe the automated process for claims review (retrospective review) that indicates when a member is prescribed the morphine equivalent for such treatment in excess of the maximum MME/daily dose limitation.
  • Concurrent utilization alerts
    Describe the automated process for claims review (retrospective) that monitors when a member is concurrently prescribed opioids and benzodiazepines or opioids and antipsychotics. (This does not preclude the establishment of a prospective safety-edit system to provide additional information to patients and providers at the point-of-sale about concurrent utilization.) Managed care plans (MCPs) and applicable entities that are not capitated for antipsychotic drugs will be provided claims data, including for antipsychotic medications. The health plan and applicable entities are expected to perform, retrospectively, regular care management activities, including a review of concurrent use of opioid and antipsychotic medications, and take action accordingly on issues of concern to them.
  • Permitted exclusions
    The above described safety edits and claims review requirements do not apply to members who are receiving hospice or palliative care; receiving treatment for cancer; residents of a long-term care facility, a facility described in section 1905(d) of the Act, or of another facility for which frequently abused drugs are dispensed for residents through a contact with a single pharmacy; members who are receiving opioid agonist medications for treatment of substance use disorder; or other individuals the state elects to treat as exempted from such requirements.

Monitoring of antipsychotic medications used by children

MCPs (and applicable entities) that are capitated for all psychiatric drugs, including antipsychotic medications, must describe the program they use to monitor and manage utilization of antipsychotic medications in children and foster children. MCPs and applicable entities must also describe the actions they will take based on DUR program monitoring. The use of antipsychotic medications outside of U.S. Food and Drug Administration-approved indications or doses needs prior authorization approval. Also, ongoing use of two or more antipsychotic medications must be medically justified and closely monitored.

Identification of fraud, waste and abuse

Describe the process for identifying and addressing fraud and abuse of controlled substances by members, health care providers who are prescribing drugs to members, and pharmacies dispensing drugs to members. Also describe the actions that will be taken based on issues identified through program-monitoring findings.

1The DUR program must comply with Medicaid-related DUR provisions contained in section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (H.R. 6, the SUPPORT Act, P.L. 115-271).

Last Updated: 05/28/2020