Ala. Admin. Code r. 560-X-16-.23

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-16-.23 - Drug Utilization Review (DUR) - General

In accordance with the Medicaid Drug Amendments contained in the Omnibus Budget Reconciliation Act of 1990, (Public Law 101-508), the following shall apply:

(1) The Medicaid Agency shall provide, by not later than January 1, 1993, for a Drug Utilization Review (DUR) Program for covered outpatient drugs in order to assure that prescriptions are appropriate, medically necessary, and are not likely to result in adverse medical results.

(2) The DUR Program is made up of the following components: Prospective Drug Utilization Review, Retrospective Drug Utilization Review, and an educational program.

(3) The Alabama Medicaid Agency has established a DUR Board. Board membership shall be composed of four practicing physicians, four practicing pharmacists, two representatives from the state's pharmacy schools, two representatives from the state's medical schools, and two representatives from the Alabama Medicaid Agency with knowledge and experience in:

(a) Clinically appropriate prescribing and dispensing of covered outpatient drugs

(b) Monitoring of covered outpatient drugs

(c) Drug use review, evaluation and intervention

(d) Medical quality assurance

(4) Physician and pharmacist DUR Board members must be licensed in Alabama.

(5) The activities of the DUR Board include:

(a) Retrospective DUR

(b) Application of prescribing standards

(c) Ongoing interventions for physicians and pharmacists targeting therapy problems or individuals identified in the course of retrospective DUR. Interventions include in appropriate instances:

1. Information dissemination

2. Written, oral, and electronic reminders

3. Face to face discussions

4. Intensified monitoring/review of providers/dispensers

(6) The DUR Program shall be designed to educate physicians and pharmacists to reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and patients associated with specific drugs, as well as potential and actual drug reactions, therapeutic appropriateness, over-utilization, under-utilization, appropriate use of generic products, therapeutic duplication, drug/disease contraindications, drug interactions, incorrect drug dosage or duration, drug allergy interactions and clinical abuse/misuse.

(7) The DUR Program will review, analyze and interpret patterns of drug usage against predetermined criteria and standards consistent with the American Medical Association Drug Evaluations, United States Pharmacopoeia Drug Index, American Hospital Formulary Service Drug Index, and peer reviewed medical literature. The predetermined criteria and standards are available from the Alabama Medicaid Agency or its designated agent.

(8) DUR will be conducted for drugs dispensed to residents of nursing facilities.

Author:

Ala. Admin. Code r. 560-X-16-.23

Emergency rule Effective July 1, 1993. Permanent rule effective October 14, 1993. Amended: January 7, 1997; effective February 11, 1997. Amended: Filed January 6, 1998; effective February 10, 1998.

Statutory Authority: State Plan, Pages 74, 74a, 74b; Title XIX, Social Security Act; 42 CFR Section 440.120; Public Law 101-508.