About Us
Drug Use Review (DUR)
In operation since 1983, the Drug Use Review (DUR) Board consists of eight pharmacists and five physicians who are active in their respective professions. The DUR Board also includes two pharmacy students representing each school/college of pharmacy in Nebraska, and pharmacist consultants from the Nebraska Medicaid Drug Program. The DUR Board members' professional experiences include family practice, internal medicine, psychiatry, pediatrics, community pharmacy practice, hospital pharmacy practice and academia.
The goals of the DUR Board are to improve the quality of pharmacy services and to ensure rational, cost-effective medication therapy for Nebraska Medicaid recipients. DUR Board members assess the utilization, quality, medical appropriateness and cost of prescribed medication through the evaluation of claims data.
The activities of the DUR Board are:
1. Conducts monthly retrospective DUR profile reviews which are either patient specific or therapeutic/problem-focused.
2. Provides prescription profile reviews for specific patients when requested by a provider or the Medicaid Department. Specific patient profile reviews are available to all Medicaid providers who have questions about their patient's drug therapy or utilization patterns.
3. Reviews policy issues and provides recommendations on a variety of topics when requested by the Medicaid Department. Areas of review include, but are not limited to, prospective DUR criteria and Prior Authorization criteria. Recommendations made to the Medicaid Department by the DUR Board are not binding upon the State in any way.
4. Informs providers of their patients' drug use patterns through provider intervention letters. Provider intervention letters are designed for educational purposes and are meant to assist the provider in the further assessment of the patient's drug therapy requirements.
The Prior Authorization Process for New Drugs
The 2005 Nebraska Medicaid Reform Plan requires Medicaid to place new drugs on Prior Authorization pending review by the Drug Utilization Review (DUR) board. The New Drug Review process was instituted to examine new drugs and formulations. These drugs generally fall into one of the following categories:
• a safety concern or require intense monitoring.
• potential for off-label or non-covered use.
• are reformulated in an attempt to prolong patent life, without
clinical benefit or for patient convenience.
• potential for abuse or misuse.
• very costly, for which lower-priced alternatives are available.
• Prior to DUR review the drug requires prior authorization.
• Coverage is limited to cases of medical necessity for recipients who:
o have failed covered therapies or covered therapies are
inappropriate.
o have diagnosis within the FDA approved indications.
o are prescribed doses within FDA approved guidelines.
o are of an age approved within the FDA guidelines.
New drugs will require Prior Authorization for 6 months and then will be reviewed by the DUR Board to determine if Prior Authorization should continue. During the 6 month-review period, prescribers may submit a Medical Necessity form to Medicaid for a patient to obtain the medication. Verification of previous therapies will be documented utilizing Medicaid paid claims data. Nebraska Medicaid may request chart documentation to verify information. The Medical Necessity form can be found at the following website: www.hhs.state.ne.us/med/pharm/.
|
