Utah Code 26B-3-307. Retrospective and prospective DUR
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(1) The board, in cooperation with the division, shall include in its state plan the creation and implementation of a retrospective and prospective DUR program for Medicaid outpatient drugs to ensure that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes.
Terms Used In Utah Code 26B-3-307
- Board: means the Drug Utilization Review Board created in Section 26B-3-302. See Utah Code 26B-3-301
- Compendia: means resources widely accepted by the medical profession in the efficacious use of drugs, including "American Hospital Formulary Service Drug Information" "U. See Utah Code 26B-3-301
- Division: means the Division of Integrated Healthcare within the department, established under Section 26B-3-102. See Utah Code 26B-3-101
- Drug-disease contraindications: means that the therapeutic effect of a drug is adversely altered by the presence of another disease condition. See Utah Code 26B-3-301
- DUR: means the program designed to measure and assess, on a retrospective and prospective basis, the proper use of outpatient drugs in the Medicaid program. See Utah Code 26B-3-301
- Fraud: Intentional deception resulting in injury to another.
- Pharmacist: means a person licensed in this state to engage in the practice of pharmacy under Title 58, Chapter 17b, Pharmacy Practice Act. See Utah Code 26B-3-301
- Physician: means a person licensed in this state to practice medicine and surgery under Section 58-67-301 or osteopathic medicine under Section 58-68-301. See Utah Code 26B-3-301
- Standards: means the acceptable range of deviation from the criteria that reflects local medical practice and that is tested on the Medicaid recipient database. See Utah Code 26B-3-301
- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- Therapeutic appropriateness: means drug prescribing and dispensing based on rational drug therapy that is consistent with criteria and standards. See Utah Code 26B-3-301
- Therapeutic duplication: means prescribing and dispensing the same drug or two or more drugs from the same therapeutic class where periods of drug administration overlap and where that practice is not medically indicated. See Utah Code 26B-3-301
- underutilization: means the use of a drug in such quantities that the desired therapeutic goal is not achieved. See Utah Code 26B-3-301
(2) The retrospective and prospective DUR program shall be operated under guidelines established by the board under Subsections (3) and (4).
(3) The retrospective DUR program shall be based on guidelines established by the board, using the mechanized drug claims processing and information retrieval system to analyze claims data in order to:
(3)(a) identify patterns of fraud, abuse, gross overuse, and inappropriate or medically unnecessary care; and
(3)(b) assess data on drug use against explicit predetermined standards that are based on the compendia and other sources for the purpose of monitoring:
(3)(b)(i) therapeutic appropriateness;
(3)(b)(ii) overutilization or underutilization;
(3)(b)(iii) therapeutic duplication;
(3)(b)(iv) drug-disease contraindications;
(3)(b)(v) drug-drug interactions;
(3)(b)(vi) incorrect drug dosage or duration of drug treatment; and
(3)(b)(vii) clinical abuse and misuse.
(4) The prospective DUR program shall be based on guidelines established by the board and shall provide that, before a prescription is filled or delivered, a review will be conducted by the pharmacist at the point of sale to screen for potential drug therapy problems resulting from:
(4)(a) therapeutic duplication;
(4)(b) drug-drug interactions;
(4)(c) incorrect dosage or duration of treatment;
(4)(d) drug-allergy interactions; and
(4)(e) clinical abuse or misuse.
(5) In conducting the prospective DUR, a pharmacist may not alter the prescribed outpatient drug therapy without the consent of the prescribing physician or physician assistant. This section does not effect the ability of a pharmacist to substitute a generic equivalent.