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.
Illinois Prescription Monitoring Program
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.
Pain Management with Opioids
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.