Medicaid Drug Utilization Review (DUR) Program

The Medicaid Drug Utilization Review (DUR) Program promotes patient safety through state-administered utilization management tools and systems that interface with CMS’ Medicaid Management Information Systems (MMIS). Medicaid DUR is a two-phase process that is conducted by the Medicaid state agencies. In the first phase (prospective DUR) the state’s Medicaid agency’s electronic monitoring system screens prescription drug claims to identify problems such as therapeutic duplication, drug-disease contraindications, incorrect dosage or duration of treatment, drug allergy and clinical misuse or abuse. The second phase (retrospective DUR) involves ongoing and periodic examination of claims data to identify patterns of fraud, abuse, gross overuse, or medically unnecessary care and implements corrective action when needed.

On an annual basis, states are required to report on their state’s prescribing habits, cost savings generated from their DUR programs and their program’s operations, including adoption of new innovative DUR practices via the Medicaid Drug Utilization Review Annual Report Survey For states’ convenience in filling out the DUR annual report, an NDC and Drug Category file [ZIP] extracted from the first quarter 2012 Medicaid drug product data file is provided.

42 CFR Subpart K – Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims, Section 456.700-456.725, provides the requirements for the DUR program.

To view the State Medicaid DUR Annual reports, please visit the Medicaid Drug Programs Data and Resources page.

Psychotropic Medication Use in Children in Foster Care
Much attention has been focused on monitoring the prescribing of psychotropic medications to children in foster care since the passage of the Child and Family Services Improvement and Innovation Act of 2011 (P.L.112-34). Children in state custody often have emotional and behavioral challenges as a result of maltreatment and trauma. Creating, coordinating and implementing monitoring protocols across various agencies (state child welfare, Medicaid and mental health systems) to ensure appropriate prescribing and monitoring of medication therapy requires careful planning.  While there is no single way to create a perfect system, state DUR programs can develop and share effective strategies for building creative and collaborative methods for promoting quality care for these vulnerable individuals. To that end, we are providing a brief summary of different actions various states have taken to address this issue, along with a list of resources.

Questions on the Drug Utilization Review Program? Email DURPolicy@cms.hhs.gov.

Page last updated on 8/23/2012