Common use of Drug Utilization Review Program Clause in Contracts

Drug Utilization Review Program. The MCO must have a process in place to conduct prospective and retrospective utilization review of prescriptions that is consistent with Medicare Part D drug utilization review standards (see 42 C.F.R. 423.153). Prospective review should take place at the dispensing pharmacy’s point-of-sale (POS). The prospective review at the POS should compare the prescribed medication against previous drug history for drug-to-drug, ingredient duplication, therapeutic duplication, and high dose situations. The MCO’s retrospective review should monitor prescriber and contracted pharmacies for outlier activities. Retrospective reviews should also determine whether services were delivered as prescribed and consistent with the MCO’s payment policies and procedures. Prior to the Operational Start Date, HHSC will transmit a file with up to one year of medication history for Members with recent Medicaid eligibility, moving from the fee-for-service program. Outgoing MCOs will transfer this data for members moving to a new MCO.