Federal rules require that each state Medicaid program include a comprehensive Drug Use Review (DUR) program to improve the quality and cost effectiveness of drug use by ensuring that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical results.
California's Medicaid DUR program is focused on outpatient medication therapies with the broad goals of improving patient outcomes, increasing the quality of prescribing practices, reducing healthcare costs, and improving beneficiary, prescriber, and pharmacist satisfaction. To work towards these goals, the DUR program implements strategies that identify and reduce adverse events, fraud, misuse, overutilization, underutilization, and inappropriate/ineffective care associated with specific drugs or groups of drugs. Strategies for improving prescribing may include education, data reports, audits, alerts, incentives, decision-making tools, and outreach aimed at beneficiaries, prescribers, and pharmacists.
There are three key functions of the DUR program:
Central to the DUR program is the Global Medi-Cal DUR Board, which is an advisory body that includes volunteer pharmacists and physicians with active practices in California. The Board advises and makes recommendations to the State on common drug therapy problems, develops criteria to evaluate and improve the quality of drug therapy, reviews evaluations and utilization reports, and recommends educational interventions, as needed, in order to improve prescribing and dispensing practices.
The DUR program promotes patient safety through state-administered utilization management tools and systems that interface with the claims processing systems. Additionally, consistent with 42 CFR §438.3(s)(4) and (5), the Centers for Medicare and Medicaid Services (CMS) requires any Managed Care Organization (MCO) that includes covered outpatient drugs to operate a DUR program compliant with section 1927(g)(3)(D) and 42 CFR 456, subpart K.