26-18-103. DUR Board -- Responsibilities.
The board shall:
(1) develop rules necessary to carry out its responsibilities as defined in this part;
(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 an annual report, subject to public comment prior to its issuance, and submit
that report to the United States Department of Health and Human Services by December 1 of
each year. That report shall also be submitted to legislative leadership, the executive director, the
president of the Utah Pharmaceutical Association, and the president of the Utah Medical
Association by December 1 of each year. The report shall include:
(a) an overview of the activities of the board and the DUR program;
(b) a description of interventions used and their effectiveness, specifying whether the
intervention was a result of underutilization or overutilization of drugs, without disclosing the
identities of individual physicians, pharmacists, or recipients;
(c) the costs of administering the DUR program;
(d) any fiscal savings resulting from the DUR program;
(e) an overview of the fiscal impact of the DUR program to other areas of the Medicaid
program such as hospitalization or long-term care costs;
(f) a quantifiable assessment of whether DUR has improved the recipient's quality of
care;
(g) a review of the total number of prescriptions, by drug therapeutic class;
(h) an assessment of the impact of educational programs or interventions on prescribing
or dispensing practices; and
(i) recommendations for DUR program improvement;
(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;
(13) establish a grievance process for physicians and pharmacists under this part, in
accordance with Title 63G, Chapter 4, Administrative Procedures Act;
(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;
(f) proper storage;
(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.
Amended by Chapter 382, 2008 General Session
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Last revised: Thursday, May 28, 2009