26B-3-303. DUR Board — Responsibilities. The board shall:
| (1) |
develop rules necessary to carry out its responsibilities as defined in this part; |
Terms Used In Utah Code 26B-3-303
- 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
- Contract: A legal written agreement that becomes binding when signed.
- Counseling: means the activities conducted by a pharmacist to inform Medicaid recipients about the proper use of drugs, as required by the board under this part. See Utah Code 26B-3-301
- Criteria: means those predetermined and explicitly accepted elements used to measure drug use on an ongoing basis in order to determine if the use is appropriate, medically necessary, and not likely to result in adverse medical outcomes. 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
- 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.
- Intervention: means a form of communication utilized by the board with a prescriber or pharmacist to inform about or influence prescribing or dispensing practices. See Utah Code 26B-3-301
- Medicaid program: means the state program for medical assistance for persons who are eligible under the state plan adopted pursuant to Title XIX of the federal Social Security Act. See Utah Code 26B-3-101
- 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
- Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
- Recipient: means a person who has received medical assistance under the Medicaid program. See Utah Code 26B-3-101
- 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
- SURS: means the Surveillance Utilization Review System of the Medicaid program. 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) |
oversee the implementation of a Medicaid retrospective and prospective DUR program in accordance with this part, including responsibility for approving provisions of contractual agreements between the Medicaid program and any other entity that will process and review Medicaid drug claims and profiles for the DUR program in accordance with this part; |
| (3) |
develop and apply predetermined criteria and standards to be used in retrospective and prospective DUR, ensuring that the criteria and standards are based on the compendia, and that they are developed with professional input, in a consensus fashion, with provisions for timely revision and assessment as necessary. The DUR standards developed by the board shall reflect the local practices of physicians in order to monitor:
| (a) |
therapeutic appropriateness; |
| (b) |
overutilization or underutilization; |
| (c) |
therapeutic duplication; |
| (d) |
drug-disease contraindications; |
| (e) |
drug-drug interactions; |
| (f) |
incorrect drug dosage or duration of drug treatment; and |
| (g) |
clinical abuse and misuse; |
|
| (4) |
develop, select, apply, and assess interventions and remedial strategies for physicians, pharmacists, and recipients that are educational and not punitive in nature, in order to improve the quality of care; |
| (5) |
disseminate information to physicians and pharmacists to ensure that they are aware of the board’s duties and powers; |
| (6) |
provide written, oral, or electronic reminders of patient-specific or drug-specific information, designed to ensure recipient, physician, and pharmacist confidentiality, and suggest changes in prescribing or dispensing practices designed to improve the quality of care; |
| (7) |
utilize face-to-face discussions between experts in drug therapy and the prescriber or pharmacist who has been targeted for educational intervention; |
| (8) |
conduct intensified reviews or monitoring of selected prescribers or pharmacists; |
| (9) |
create an educational program using data provided through DUR to provide active and ongoing educational outreach programs to improve prescribing and dispensing practices, either directly or by contract with other governmental or private entities; |
| (10) |
provide a timely evaluation of intervention to determine if those interventions have improved the quality of care; |
| (11) |
publish the annual Drug Utilization Review report required under 42 C.F.R. § 712; |
| (12) |
develop a working agreement with related boards or agencies, including the State Board of Pharmacy, Physicians’ Licensing Board, and SURS staff within the division, in order to clarify areas of responsibility for each, where those areas may overlap; |
| (14) |
publish and disseminate educational information to physicians and pharmacists concerning the board and the DUR program, including information regarding:
| (a) |
identification and reduction of the frequency of patterns of fraud, abuse, gross overuse, inappropriate, or medically unnecessary care among physicians, pharmacists, and recipients; |
| (b) |
potential or actual severe or adverse reactions to drugs; |
| (c) |
therapeutic appropriateness; |
| (d) |
overutilization or underutilization; |
| (e) |
appropriate use of generics; |
| (f) |
therapeutic duplication; |
| (g) |
drug-disease contraindications; |
| (h) |
drug-drug interactions; |
| (i) |
incorrect drug dosage and duration of drug treatment; |
| (j) |
drug allergy interactions; and |
| (k) |
clinical abuse and misuse; |
|
| (15) |
develop and publish, with the input of the State Board of Pharmacy, guidelines and standards to be used by pharmacists in counseling Medicaid recipients in accordance with this part. The guidelines shall ensure that the recipient may refuse counseling and that the refusal is to be documented by the pharmacist. Items to be discussed as part of that counseling include:
| (a) |
the name and description of the medication; |
| (b) |
administration, form, and duration of therapy; |
| (c) |
special directions and precautions for use; |
| (d) |
common severe side effects or interactions, and therapeutic interactions, and how to avoid those occurrences; |
| (e) |
techniques for self-monitoring drug therapy; |
| (g) |
prescription refill information; and |
| (h) |
action to be taken in the event of a missed dose; and |
|
| (16) |
establish procedures in cooperation with the State Board of Pharmacy for pharmacists to record information to be collected under this part. The recorded information shall include:
| (a) |
the name, address, age, and gender of the recipient; |
| (b) |
individual history of the recipient where significant, including disease state, known allergies and drug reactions, and a comprehensive list of medications and relevant devices; |
| (c) |
the pharmacist’s comments on the individual’s drug therapy; |
| (d) |
name of prescriber; and |
| (e) |
name of drug, dose, duration of therapy, and directions for use. |
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Renumbered and Amended by Chapter 306, 2023 General Session
