Drug Utilization Review Requirements

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.

Claims review requirements

The requirements include the topics listed below.

Concurrent utilization alerts:

• Describe the process for claims review (retrospective) that monitors when the member is concurrently prescribed opioids and benzodiazepines or opioids and antipsychotics. The Plan and applicable entities are provided claims data, including for antipsychotic medications. The 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.

 What’s excluded from the program:

• The above described claims review requirements do not apply to the Plan 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; Plan 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

The plan and applicable entities are required to have a process to monitor and manage appropriate use of all psychiatric drugs to include antipsychotics, mood stabilizers and anti-depressant medications for all children under age 18 and all foster children. Based on the DUR program monitoring findings, the DUR program must have a process to address and improve concerning findings.

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).