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 Drug Utilization Review Board (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 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.
Drug Utilization Review. Drug Utilization Review Board (pdf)
Pain Management with Opioids
Safe use of acetaminophen-containing combination products (pdf)
Migraine Prophylaxis (pdf) (html)
Resources for Managing Vitamin D Therapy (pdf)
Claims Processing Drug Utilization Control Edits
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.
Prior Authorization requests are received to override an edit that is in place for a medication. Below are some examples of duplicate therapy, drug interactions, and inappropriate therapy that have been addressed as a result of edits that required review for prior authorization.
Example #1: 45 year old man with diagnoses of depression, schizophrenia, and anxiety
Example #2: 42 year old male with diagnosis of allergic rhinitis and asthma
Example #3: 40 year old female with diagnosis of type 2 diabetes
Example #4: 56 year old male with diagnosis of dyslipidemia
Example #5: A 69 year old male with a diagnosis of post-operative (post-op) pain and hyperlipidemia
Example #6: A 55 year old female with a diagnosis of diabetes