26-18-107 - Retrospective and prospective DUR.
26-18-107. Retrospective and prospective DUR.
(1) The board, in cooperation with the division, shall include in its state plan the creationand implementation of a retrospective and prospective DUR program for Medicaid outpatientdrugs to ensure that prescriptions are appropriate, medically necessary, and not likely to result inadverse medical outcomes.
(2) The retrospective and prospective DUR program shall be operated under guidelinesestablished by the board under Subsections (3) and (4).
(3) The retrospective DUR program shall be based on guidelines established by theboard, using the mechanized drug claims processing and information retrieval system to analyzeclaims data in order to:
(a) identify patterns of fraud, abuse, gross overuse, and inappropriate or medicallyunnecessary care; and
(b) assess data on drug use against explicit predetermined standards that are based on thecompendia and other sources for the purpose of monitoring:
(i) therapeutic appropriateness;
(ii) overutilization or underutilization;
(iii) therapeutic duplication;
(iv) drug-disease contraindications;
(v) drug-drug interactions;
(vi) incorrect drug dosage or duration of drug treatment; and
(vii) clinical abuse and misuse.
(4) The prospective DUR program shall be based on guidelines established by the boardand shall provide that, before a prescription is filled or delivered, a review will be conducted bythe pharmacist at the point of sale to screen for potential drug therapy problems resulting from:
(a) therapeutic duplication;
(b) drug-drug interactions;
(c) incorrect dosage or duration of treatment;
(d) drug-allergy interactions; and
(e) clinical abuse or misuse.
(5) In conducting the prospective DUR, a pharmacist may not alter the prescribedoutpatient drug therapy without the consent of the prescribing physician. This section does noteffect the ability of a pharmacist to substitute a generic equivalent.
Enacted by Chapter 273, 1992 General Session