Drug Utilization Review Board (DUR Board)

Federal regulations at eCFR § 42 CFR 456.703 -- Drug use review program. require that state Medicaid pharmacy programs establish and maintain a Drug Utilization (DUR) program that helps ensure appropriate drug utilization by conducting prospective and retrospective drug utilization review, and maintaining an educational program.

Prospective Drug Utilization Review

Prospective DUR occurs at point-of-sale. Pharmacists review drug therapy at point-of-sale to screen for therapeutic duplication, drug-disease contraindication, adverse drug-drug interactions, incorrect drug doses or durations of therapy, drug-allergy interactions, and clinical abuse/misuse. Pharmacists then counsel HFS clients regarding their medications according to state standards. Claims processing edits and prior authorization criteria for medications can impact this process. Prior approval status of a medication is searchable at Drug Search (ilpriorauth.com)

Retrospective Drug Utilization Review

Retrospective DUR periodically evaluates drug claims data and other records to monitor for fraud, therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindication, drug-drug interactions, incorrect drug dosage, incorrect duration of drug therapy, and clinical abuse or misuse. Physician prescribing practices, drug use by individual clients, and as appropriate, dispensing practices of pharmacies are evaluated.

The Illinois Department of Healthcare and Family Services (HFS) reviews retrospective DUR data based on drug claims to identify problematic utilization patterns and implements edits in the claims processing system to prevent inappropriate utilization such as therapeutic duplication, excessive duration of therapy, off-label use of drugs without clinical support, and filling of unnecessary drugs/products. Once a claims processing edit is in place, on a case-by-case basis and where appropriate, HFS can override an edit through the drug prior approval system.

Education

Patient-specific or drug-specific information and recommendations for changes in prescribing or dispensing practices may be communicated verbally or via written or electronic formats as part of the prior authorization process. Face-to-face discussions may be conducted as part of targeted educational interventions for prescribing, dispensing, or pharmacy care practices.

As part of the drug utilization review process common clinical issues for which updated educational information might be useful are identified. Educational materials are prepared by the department and the University of Illinois at Chicago College of Pharmacy and approved by the DUR Board. The educational materials are intended to be a resource for prescribers in an effort to improve the quality of care for our clients. Educational materials are posted on the Drug Utilization Review | HFS (illinois.gov) webpage.

Drug Utilization Review Board

The federal regulation eCFR § 42 CFR 456.703 -- Drug use review program. also requires state Medicaid pharmacy programs to establish and maintain a DUR Board. The mission of the Illinois HFS DUR Board is to work with the agency to improve medication utilization in patients insured by Medicaid. The DUR Board meets quarterly to review and make recommendations on prospective and retrospective drug utilization review criteria and to identify and develop educational initiatives to improve prescribing or dispensing practices. Periodically the DUR Board evaluates the established criteria and their usage as well as the educational initiatives and recommends changes to HFS. The Drug Utilization Review Board (DUR Board) | HFS (illinois.gov) webpage provides information about the DUR Board meetings.

Approved by the Illinois DUR Board on February 18, 2015