Drug Utilization Review

 
2
 
Medicaid & Long-Term Care
No

What would you like to do?

What you need to know

The Nebraska Drug Utilization 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 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.  Activities of the DUR Board include:

  1. Conduct monthly retrospective DUR profile reviews which are either patient specific or therapeutic/problem-focused.
  2. Provide 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. Review policy issues and provide 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. Inform 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.

If you have any questions about the Nebraska DUR Board, contact the Nebraska DUR program at DHHS.MedicaidPharmacyUnit@Nebraska.gov.

New Drug Review

The 2005 Nebraska Medicaid Reform Plan required Medicaid to place new drugs on Prior Authorization pending review. Drugs that are included in the Preferred Drug List are reviewed by the P & T Committee, all others are reviewed by the Nebraska 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:
    • Have failed covered therapies or covered therapies are inappropriate.
    • Have diagnosis within the FDA approved indications.
    • Are prescribed doses within FDA approved guidelines.
    • Are of an age approved within the FDA guidelines.

New drug products require Prior Authorization for 6 months. The 6 month Prior Authorization period begins on the date on which a valid claim for a bona fide prescription could be paid for by Medicaid through the Ne-POP system. 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 are documented utilizing Medicaid paid claims data. Nebraska Medicaid may request chart documentation to verify the information. A representative of the manufacturer is required to contact the Nebraska DUR Director and request a review to remove the New Drug Prior Authorization. Twenty copies of the Prescribing Information shall be provided to the DUR Director. If any additional drug information is required, it will be requested.

Meetings and Agendas

Recommendations for review topics and comments and suggestions about the Nebraska Medicaid DUR program can be directed to DHHS.MedicaidPharmacyUnit@Nebraska.gov.

Meeting agendas are posted to the website 30 days prior to the scheduled meeting. From the date that the agenda is posted until after the DUR Board meeting is held, it is inappropriate for anyone receiving compensation from a pharmaceutical manufacturer, to contact a Board member regarding DUR Board agenda items.  If a Board Member is contacted by anyone receiving compensation from a pharmaceutical manufacturer, no public comment will be allowed on that manufacturer's agenda item during that DUR Board meeting.  If a DUR Board Member is contacted about an agenda item, it shall be reported to the DUR Director.

DUR Board meetings are open to the public for attendance. Guidelines for public comment at DUR Board meetings include:

  • Unsolicited presentations are limited to 5 minutes per drug or topic, regardless of the number of presenters and time will be evenly divided among presenters.
  • Written materials may be distributed to DUR Board members if 20 copies are supplied to the Director 15 days prior to the scheduled meeting.

 

DUR Board Meeting Dates & Agendas