Retrospective and prospective DUR.

  1. Law
  2. Utah Code
  3. Utah Health Code
  4. Medical Assistance Act
  5. Drug Utilization Review Board
  6. Retrospective and prospective DUR.

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Affected by 63I-1-226 on 7/1/2027

Effective 5/14/2019
26-18-107. Retrospective and prospective DUR.
  • (1) The board, in cooperation with the division, shall include in its state plan the creation and implementation of a retrospective and prospective DUR program for Medicaid outpatient drugs to ensure that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes.
  • (2) The retrospective and prospective DUR program shall be operated under guidelines established by the board under Subsections (3) and (4).
  • (3) The retrospective DUR program shall be based on guidelines established by the board, using the mechanized drug claims processing and information retrieval system to analyze claims data in order to:
    • (a) identify patterns of fraud, abuse, gross overuse, and inappropriate or medically unnecessary care; and
    • (b) assess data on drug use against explicit predetermined standards that are based on the compendia and other sources for the purpose of monitoring:
      • (i) therapeutic appropriateness;
      • (ii) overutilization or underutilization;
      • (iii) therapeutic duplication;
      • (iv) drug-disease contraindications;
      • (v) drug-drug interactions;
      • (vi) incorrect drug dosage or duration of drug treatment; and
      • (vii) clinical abuse and misuse.
  • (4) The prospective DUR program shall be based on guidelines established by the board and shall provide that, before a prescription is filled or delivered, a review will be conducted by the pharmacist at the point of sale to screen for potential drug therapy problems resulting from:
    • (a) therapeutic duplication;
    • (b) drug-drug interactions;
    • (c) incorrect dosage or duration of treatment;
    • (d) drug-allergy interactions; and
    • (e) clinical abuse or misuse.
  • (5) In conducting the prospective DUR, a pharmacist may not alter the prescribed outpatient drug therapy without the consent of the prescribing physician or physician assistant. This section does not effect the ability of a pharmacist to substitute a generic equivalent.




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