Drug Utilization Review

Federal regulations at 42 C.F.R.  456.703 - 456.725 require that Medicaid pharmacy programs establish and maintain a Drug Utilization Review (DUR) program that helps to ensure appropriate drug utilization by conducting prospective and retrospective drug utilization review, and maintaining an educational program. These regulations also require that state Medicaid pharmacy programs establish and maintain a DUR Board. More information about the DUR Board, including membership lists, meeting schedules, and meeting minutes can be found on the DUR Board Web page.

As part of the drug utilization review process, including those reviews performed under the Four Prescription Policy, the department identifies common clinical issues for which updated educational information might be useful. These educational materials, which have been prepared by the department and the University of Illinois at Chicago College of Pharmacy, and approved by the Drug Utilization Review Board, are intended to be a resource for prescribers in an effort to improve the quality of care for our beneficiaries.  

• U.S. Surgeon General's Advisory on Naloxone and Opioid Overdose

• CDC Guideline for prescribing opioids for chronic pain - United States, 2016
• CDC Guidelines At-A-Glance

• FDA's Opioid Analgesic REMS Patient Counseling guide (pdf) Spanish version (pdf)
• FDA's Opioid Analgesic REMS Education Blueprint for Health Care Providers Involved in the Treatment and Monitoring of Patients with Pain (pdf)
• FDA: The Opioid Epidemic: What veterinarians need to know
• FDA limits use of opioid containing cough and cold products in children
• FDA's new black box warning about concomitant use of opioids with benzodiazepines   
•  FDA's new black box warning about concomitant use of opioids with benzodiazepines. FDA's new black box warning about concomitant use of opioids with benzodiazepines
• FDA's new black box warning about concomitant use of opioids with benzodiazepines

• Use of medications containing codeine and tramadol in children (pdf)
• U.S. Department of Health and Human Services: Opioids: the prescription drug and heroin overdose epidemic
• Fentanyl products non-preferred in Illinois Medicaid (pdf)
• Methadone for pain non-preferred in Illinois Medicaid (pdf)
• Opioid Pain Management: Provider Continuing Education Resources (pdf) (html)

• Opioids for chronic noncancer pain. A position paper of the American Academy of Neurology
• Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain (pdf)
• Safe Narcotic Prescribing (pdf)

Effective January 1, 2018, the Illinois Controlled Substances Act was amended. All Illinois prescribers with an Illinois controlled substances license must register with the Prescription Monitoring Program and attempt to access the program to assess patient access to controlled substances. Please see the Illinois Prescription Monitoring program webpage for more information.

• GINA guidelines
• 2024 Global Strategy for Asthma Management and Prevention (2024 update)
• “What’s New in 2024” Slide Set from 2024 GINA Report

• National Asthma Education and Prevention Program (NAEPP) Asthma Management Guidelines: Focused Updates 2020

• VA: Re-evaluating the use of benzodiazepines. A focus on high-risk populations https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Academic_Detailing_Educational_Material_Catalog/22_Benzodiazepine_Provider_AD_Educational_Guide_IB_10_928.pdf 

• VA: Patient/Provider Discussion Guide: Benzodiazepine risks, discontinuation, and taper. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Academic_Detailing_Educational_Material_Catalog/24_Benzodiazepines_Provider_AD_Risk_Discussion_Guide_IB10_953.pdf

• Judicious prescribing of benzodiazepines from NY City Dept Health and Mental Hygiene  http://www1.nyc.gov/assets/doh/downloads/pdf/chi/chi-35-2.pdf

  • Safe prescribing of benzodiazepines for anxiety and insomnia from Pennsylvania. http://www.overdosefreepa.pitt.edu/wp-content/uploads/2016/10/Benzo-for-anxiety-and-insomnia-FINAL-002.pdf 

• Guideline update. 2013 ACC/AHA cholesterol guidelines (pdf)
• Appropriate statin therapy (pdf)

• Management of Type 2 diabetes (pdf)
• Diabetes (pdf) (html)

HFS routinely reviews drug claims to identify problematic utilization patterns. As a result, HFS 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, the Department can override an edit through the drug prior approval system.  

• Archived DUR Documents