Drug Utilization Review Requirements
- Participating Physician Groups (PPG)
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 Retrospective DUR Program
The requirements include the topics listed below.
- Review of maximum daily morphine milligram equivalents (MME) safety edits
- Describe the 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.
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).