Drug Utilization Review

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. On July 1, 2016, CMS sent the Newly Revised Medicaid Drug Utilization Review Annual Report Survey to each state. This new survey has an expanded Fraud, Waste and Abuse section, new questions in the Prescription Drug Monitoring Program section and questions regarding state Managed Care Organizations.  For the states’ convenience in completing the FFY 2015 DUR annual report, an NDC and Drug Category file extracted from the fourth quarter 2015 Medicaid Drug product data file is provided. View the previous version of the Medicaid Drug Utilization Review Annual Report.

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.

Medicaid Drug Utilization Review (DUR) Annual Reports

The FFY 2015 DUR annual reports are now posted and can be viewed at Medicaid Drug Programs Data and Resources. 

FFY 2015 Drug Utilization Review

The fee-for-service data from the FFY 2015 DUR reports have been compiled and presented in a similar format to last year in one State Comparison/Summary Report FFY 2015

FFY 2014 Drug Utilization Review

The fee-for-service data from the FFY 2014 DUR reports has been compiled and presented in a similar format to last year in one State Comparison/Summary Report FFY 2014

FFY 2013 Drug Utilization Review

The fee-for-service data from the FFY 2013 DUR reports has been compiled and presented in a similar format to last year in one State Comparison/Summary Report FFY 2013. A Table of Contents has been added to the State Comparison/ Summary Report to aid interested parties in reviewing the findings. A compilation of the 2013 Executive Summary Reports will be posted in the near future, depicting an overview of DUR activities during the FFY 2013.

FFY 2012 Drug Utilization Review

The fee-for-service data from the FFY 2012 DUR reports has been compiled and presented in an improved format over last year by combining data from the two reports previously posted, the Comparison Report and the Summary Report into one Comparison/Summary Report. A Table of Contents has been added to the Comparison/ Summary Report to aid interested parties in reviewing the findings. A compilation of the 2012 Executive Summary Reports will be posted in the near future.

FFY 2011 Drug Utilization Review 

The fee for service FFY 2011 DUR reports have been presented in several sections to allow interested parties to see a comparison of the findings. The first section is a Comparison Report, detailing state-by-state listing of each state’s response to the questions in the survey. The second section is a Summary Report of all states’ responses to individual questions. The third section is a compilation of the unedited Executive Summary Reports submitted at the state’s option, depicting an overview of DUR activities during the FFY 2011.

Antipsychotic Medication Use in Children

Much attention has been focused on monitoring the prescribing of antipsychotic 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.

Generally, each state Medicaid pharmacy program is actively monitoring the prescribing of antipsychotic drugs with edits, which are specified parameters that prompt for a review of the prescription claim before it is authorized for payment, unless restricted by state law. The majority of states report that they have expanded their antipsychotic monitoring programs to include all children. 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 various state summaries of strategic approaches they submitted in February of 2016 to address this issue.

Innovative Practices

CMCS has reviewed the Opioid and Opioid-related Innovative Practices that the states submitted in their 2014 DUR Annual Reports. We want to share the useful information below on the activities states are performing to improve the quality of care and prudent delivery of their programs. Please note that the examples provided do not reflect all the different approaches that states may be using as these were submitted at state option. The detailed descriptions of specific state opioid-related sections were taken directly from the 2014 DUR reports submitted by the states. CMS did not edit the material submitted.

Colorado, Delaware, California and Illinois have provided their opioid and opioid- related innovative practices. For details, please click on this link:

If you would like additional information about any of these programs, please contact the person listed in the contact information in the individual 2014 state report found at this link.

More on the Opioid Epidemic

Combatting the epidemic of opioid misuse, overdoses and addiction is the focus of a Department of Health and Human Services multipronged initiative. The initiative involves actions to improve opioid prescribing and risk mitigation strategies, increase the dissemination of overdose prevention education and expand use of naloxone (a prescription drug that reverses opioid overdoses) as well as access to substance use disorder (SUD) treatment, including medication assisted treatment for opioid use disorders.

In September of 2015, CMCS hosted a webinar to recommend that states review their preferred drug lists in conjunction with various resources (i.e. P&T committees, DUR Board) to ensure appropriate utilization of methadone. The webinar also clarified to State Medicaid program staff that many of the same measures used to ensure the appropriate use of methadone may be applied to any opioid to decrease the abuse or misuse of the drug, potentially decreasing opioid deaths. 

In January of 2016, CMCS issued an informational bulletin highlighting emerging best practices for preventing opioid-related harms. The bulletin described several Medicaid pharmacy benefit management strategies for mitigating prescription drug abuse, and discussed strategies to increase the provision of naloxone to reverse opioid overdose and reduce opioid-related overdose deaths. Wherever possible, the bulletin provided examples of strategies states can use to target the prescribing of methadone for pain relief, given the disproportionate share of opioid-related overdose deaths associated with methadone when used as a pain reliever. The CMCS information bulletin may be found at this link.

Page last updated on August 31, 2016