(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. Renumbered and Amended by Chapter 306, 2023 General Session
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