Drug Utilization Review Requirements

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Ancillary

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) 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).