Form CMS-R-153 Medicaid Drug Utilization Review Annual Report

OMB approved # 0938-0659
MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT
FEDERAL FISCAL YEAR
Section 1927 (g) (3) (D) of the Social Security Act (the Act) requires each State to submit an annual
report on the operation of its Medicaid Drug Utilization Review (DUR) program. Such reports are to
include: descriptions of the nature and scope of the prospective and retrospective DUR programs; a
summary of the interventions used in retrospective DUR and an assessment of the education program;
a description of DUR Board activities; and an assessment of the DUR program’s impact on quality of
care as well as any cost savings generated by the program.
This report covers the period October 1,
to September 30,
and is due for submission to
CMS Central Office by no later than June 30,
. Answering the attached questions and
returning the requested materials as attachments to the report will constitute compliance with
the above- mentioned statutory requirement

If you have any questions regarding the DUR Annual Report, please contact
CMS: [email protected].

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid O.M.B. control number. The valid O.M.B. control number for this information collection is 0938-0659.
The time required to complete this information collection is estimated to average 32 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C426-05, Baltimore, Maryland 21244-1850.

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MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT
FEDERAL FISCAL YEAR
I.

DEMOGRAPHIC INFORMATION
State Name Abbreviation

Medicaid Agency Information
Identify State person responsible for DUR Annual Report Preparation.
Name:
Email Address:
Area Code/Phone Number:
II.

PROSPECTIVE DUR (ProDUR)
Identify by name and indicate the type of your pharmacy POS vendor – (contractor, stateoperated other).

1. If not state-operated, is the POS vendor also the MMIS fiscal agent?
☐

Yes

☐

No

2. Identify prospective DUR criteria source.
☐

First Data Bank ☐

Medi-Span

☐

Other

If the answer above is “Other,” please specify.

3. Are new prospective DUR criteria approved by the DUR Board?
☐

Yes

☐

No
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If answer above is “No,” please explain.

4. When the pharmacist receives a ProDUR alert message that requires a pharmacist’s review,
does your system allow the pharmacist to override the alert using the “conflict, intervention
and outcome” codes?
☐

Yes

☐

No

5. How often do you receive and review periodic reports providing individual pharmacy provider
activity in summary and in detail?
☐

☐

Monthly

Quarterly

☐

Annually

☐

Never

a) If the answer above is “Never,” please explain why you do not receive and review
the reports.

b) If you receive reports, do you follow-up with those providers who routinely override
with interventions?
☐

Yes

☐

No

c) If the answer to (b) above is “Yes,” by what method do you follow-up?
☐ Contact Pharmacy
☐ Refer to Program Integrity for Review
☐ Other, please explain.

d) If the answer to (b) above is “No,” please explain why you do not follow-up with
providers.

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6. Early Refill:
a) At what percent threshold do you set your system to edit?
Non-controlled drugs:

%

Controlled drugs:

%

b) When an early refill message occurs, does the state require prior authorization?
Non-controlled drugs:

☐

Yes

☐

No

Controlled drugs:

☐

Yes

☐

No

c) For non-controlled drugs, if the answer to (b) above is “Yes,” who obtains authorization?
☐

Pharmacist ☐

Prescriber

☐

Either

d) For controlled drugs, if the answer to (b) above is “Yes,” who obtains authorization?
☐

Pharmacist ☐

Prescriber

☐

Either

e) For non-controlled drugs, if the answer to (b) above is “No,” can the pharmacist override
at the point of service?
☐

Yes

☐

No

f) For controlled drugs, if the answer to (b) above is “No,” can the pharmacist override at
the point of service?
☐

Yes

☐

No

7. When the pharmacist receives an early refill DUR alert message that requires the
Pharmacist’s review, does your state’s policy allow the pharmacist to override for situations
such as:
a) Lost/stolen Rx
☐
Yes ☐
No
b) Vacation
☐
Yes ☐
No
c) Other, please explain.

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8. Does your system have an accumulation edit to prevent patients from continuously filling
prescriptions early?
☐

Yes

☐

No

a) If “Yes,” please explain your edit.

b) If “No,” do you plan to implement this edit?
☐

Yes

☐

No

9. Does the state or the state’s Board of Pharmacy have any policy prohibiting the auto-refill
process that occurs at the POS?
☐

Yes

☐

No

10. Has the state provided the DUR data requested on Table 1 – Top Drug Claims Data Reviewed
by the DUR Board?
☐

Yes

☐

No

11. Section 1927(g)(A) of the Social Security Act requires that the pharmacist offer patient
counseling at the time of dispensing. Who in your state has responsibility for monitoring
compliance with the oral counseling requirement? Check all that apply:
a) ☐
b) ☐
c) ☐

Medicaid agency
State Board of Pharmacy
Other, please explain.

12. Has the state included Attachment 1 – Pharmacy Oral Counseling Compliance Report a
report on state efforts to monitor pharmacy compliance with the oral counseling
requirement?
☐

Yes

☐

No
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III.

RETROSPECTIVE DUR (RetroDUR)
1. Identify, by name and type, the vendor that performed your RetroDUR activities during the
time period covered by this report (company, academic institution, or other organization).

a) Is the RetroDUR vendor also the Medicaid fiscal agent?
☐

Yes

☐

No

b) Is the RetroDUR vendor also the developer/supplier of your retrospective DUR criteria?
☐

Yes

☐

No

If “No,” please explain.

2. Does the DUR Board approve the RetroDUR criteria?
☐

Yes

☐

No

If “No,” please explain.

3. Has the state included Attachment 2 – Retrospective DUR Educational Outreach
Summary, a year end summary of the Top 10 problem types for which educational
interventions were taken?
☐

IV.

Yes

☐

No

DUR BOARD ACTIVITY
1. State is including a brief summary of DUR Board activities and meeting minutes during
the time period covered by this report as Attachment 3 - Summary of DUR Board
Activities.
☐

Yes

☐

No
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2. Does your state have a Disease Management Program?
☐

☐

Yes

No

a) If “Yes,” have you performed an analysis of the program’s effectiveness?
☐

Yes

☐

No

b) If the answer to (a) above is “Yes,” please provide a brief summary of your findings:

c) If the answer to (number 2) above is “Yes,” is your DUR Board involved with this
program?
☐

Yes

☐

No

3. Does your state have an approved CMS Medication Therapy Management Program?
☐
a)

☐

Yes

No

If “Yes,” have you performed an analysis of the program’s effectiveness?
☐

Yes

☐

No

b)

If the answer to (a) above is “Yes,” please provide a brief summary of your findings.

c)

If the answer to (number 3) above is “Yes,” is your DUR Board involved with this
program?
☐

Yes

☐

No

d) If the answer to (number 3) above is “No,” are you planning to develop and implement
a program?
☐ Yes

☐

No

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V.

PHYSICIAN ADMINISTERED DRUGS
The Deficit Reduction Act required collection of NDC numbers for covered outpatient
physician administered drugs. These drugs are paid through the physician and hospital
programs. Has your MMIS been designed to incorporate this data into your DUR criteria
for:
1. ProDUR?
☐

Yes

☐

No

If “No,” do you have a plan to include this information in your DUR criteria in the future?
☐

Yes

☐

No

2. RetroDUR?
☐

Yes

☐

No

If “No,” do you have a plan to include this information in your DUR criteria in the future?
☐

VI.

Yes

☐

No

GENERIC POLICY AND UTILIZATION DATA
1. State is including a description of policies that may affect generic utilization percentage as
Attachment 4 - Generic Drug Substitution Policies.
☐

Yes

☐

No

2. In addition to the requirement that the prescriber write in his own handwriting “Brand
Medically Necessary” for a brand name drug to be dispensed in lieu of the generic equivalent,
does your state have a more restrictive requirement?
☐

Yes

☐

No

If “Yes,” check all that apply:
a)
b)
c)
d)

☐
☐
☐
☐

Require that a MedWatch Form be submitted
Require medical reason for override accompany prescriptions
Prior authorization is required
Other, please explain.
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3. Indicate the generic utilization percentage for all covered outpatient drugs paid during
this reporting period, using the computation instructions in Table 2 - Generic
Utilization Data
Number of Generic Claims
Total Number of Claims
Generic Utilization Percentage
4. Indicate the percentage dollars paid for generic covered outpatient drugs in relation to all
covered outpatient drug claims paid during this reporting period using the computation
instructions in Table 2 - Generic Utilization Data
Generic Dollars:
Total Dollars:
Generic Expenditure Percentage:
VII.

PROGRAM EVALUATION / COST SAVINGS/COST AVOIDANCE
1. Did your state conduct a DUR program evaluation of the estimated cost savings/cost
avoidance?
☐

Yes

☐

No

2. Who conducted your program evaluation for the cost savings estimate/cost avoidance?
(company, academic institution, other institution) (name)

3. Please provide your ProDUR and RetroDUR program cost savings/cost avoidance in the chart
below.
ProDUR Total Estimated Avoided Costs
RetroDUR Total Estimated Avoided Costs
Other cost avoidance
Grand Total estimated Avoided Costs

4. Please provide the estimated percent impact of your state’s cost savings/cost avoidance
program compared to total drug expenditures for covered outpatient drugs.
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Use the following formula:
Divide the estimated Grand Total Estimated Avoided Costs from Question 3 above
by the total dollar amount provided in Section VI, Question 4. Then multiply this
number by 100.
Grand Estimated Net Savings Amount ÷ Total Dollar Amount × 100 =

%

5. State has provided the Medicaid Cost Savings/Cost Avoidance Evaluation as
Attachment 5 – Cost Savings/Cost Avoidance Methodology.
☐

Yes

☐

No

VIII. FRAUD, WASTE, AND ABUSE DETECTION
A. LOCK-IN or PATIENT REVIEW AND RESTRICTIVE PROGRAMS
1. Do you have a documented process in place that identifies potential fraud or abuse of
controlled drugs by beneficiaries?
☐

Yes

☐

No

If “Yes,” what actions does this process initiate? Check all that apply.
a)
b)
c)
d)

☐
☐
☐
☐

Deny claims and require prior authorization
Refer to Lock In Program
Refer to Program Integrity Unit
Other (e.g. SURS, Office of Inspector General), please explain.

2. Do you have a “lock-in” program for beneficiaries with potential misuse or abuse of
controlled substances?
☐

Yes

☐

No

If “Yes,” what criteria does your state use to identify candidates for lock-in? Check all that
apply.
☐ Number of controlled substances (CS)
☐ Different prescribers of CS
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☐
☐
☐
☐
☐

Multiple pharmacies
Number days’ supply of CS
Exclusivity of short acting opioids
Multiple ER visits
Other

If “Yes,” do you restrict the beneficiary to:
i.
a prescriber only
☐
Yes
ii.
a pharmacy only
☐
Yes
iii.
a prescriber and pharmacy ☐
Yes

☐
☐
☐

No
No
No

What is the usual “lock-in” time period?
☐ 6 months
☐ 12 months
☐ Other, please explain.

3. On the average, what percentage of the FFS population is in lock-in status annually?
%
4. Please provide an estimate of the savings attributed to the lock-in program for the fiscal year
under review.
$
5. Do you have a documented process in place that identifies possible fraud or abuse of
controlled drugs by prescribers?
☐

Yes

☐

No

If “Yes,” what actions does this process initiate? Check all that apply.
a)
b)
c)
d)

☐
☐
☐
☐

Deny claims written by this prescriber
Refer to Program Integrity Unit
Refer to the appropriate Medical Board
Other, please explain.

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6. Do you have a documented process in place that identifies potential fraud or abuse of
controlled drugs by pharmacy providers?
☐

Yes

☐

No

If “Yes,” what actions does this process initiate? Check all that apply
a)
b)
c)
d)

☐
☐
☐
☐

Deny claim
Refer to Program Integrity Unit
Refer to Board of Pharmacy
Other, please explain:

7. Do you have a documented process in place that identifies potential fraud or abuse of noncontrolled drugs by beneficiaries?
☐

Yes

☐

No

If “Yes,” please explain your program for fraud, waste, or abuse of non-controlled substances.

B. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
1. Does your state have a Prescription Drug Monitoring Program (PDMP)?
☐

Yes

☐

No

a) If the answer above is “Yes,” does your agency have the ability to query the state’s PDMP
database?
☐

Yes

☐

No

b) If the answer to (number 1) above is “Yes,” do you require prescribers (in your provider
agreement with the agency) to access the PDMP patient history before prescribing restricted
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substances?
☐ Yes

☐

No

c) If the answer to (number 1) above is “Yes,” please explain how the state applies this
information to control fraud and abuse.

d) If the answer to (number 1) above is “Yes,” do you also have access to border states’
PDMP information?
☐

☐

Yes

No

2. Are there barriers that hinder the agency from fully accessing the PDMP that prevent the
program from being utilized the way it was intended to be to curb abuse?
☐

Yes

☐

No

If “Yes,” please explain the barriers (e.g. lag time in prescription data being submitted,
prescribers not accessing, pharmacists unable to view prescription history before filling script)

3. Have you had any changes to your state’s Prescription Drug Monitoring Program during this
reporting period that have improved the agency’s ability to access PDMP data?
☐

Yes

☐

No

If “Yes,” please explain.

C. PAIN MANAGEMENT CONTROLS
1. Does your state or your agency require that Pain Management providers be certified?
☐

Yes

☐

No
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2

Does your program obtain the DEA Active Controlled Substance Registrant’s File in order to
identify prescribers not authorized to prescribe controlled drugs?
☐

Yes

☐

No

a) If the answer above is “Yes,” do you apply this DEA file to your ProDUR POS edits to
prevent unauthorized prescribing?
☐ Yes

☐

No

b) If the answer to (a) above is “Yes,” please explain how the information is applied

c) If the answer to (a) above is “No,” do you plan to obtain the DEA Active Controlled
Substance Registrant’s file and apply it to your POS edits?
☐ Yes

☐

No

3. Do you apply this DEA file to your RetroDUR reviews?
☐

Yes

☐

No

If “Yes,” please explain how it is applied.

4. Do you have measures in place to either monitor or manage the prescribing
of methadone for pain management?
☐

Yes

☐

No

☐

Other

If “Yes,” please check all that apply.
☐
☐
☐
☐
☐
☐

Pharmacist override
Deny claim and require PA
Quantity limits
Intervention letters
Morphine equivalent daily dose program
Step therapy or Clinical criteria
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If “No” or “Other,” please explain what you do in lieu of the above or why you do not have
measures in place to either manage or monitor the prescribing of methadone for pain
management.

D. OPIOIDS
1. Do you currently have POS edits in place to limit the quantity of short-acting opioids?
☐

Yes

☐

No

a) If “Yes,” what is your maximum daily limit in terms of number of units (i.e. tablets,
capsules)?
units/day
b) If “Yes,” what is your maximum days supply per prescription limitation?
☐ 30 day supply
☐ 90 day supply
☐ Other, please explain.

2. Do you currently have POS edits in place to limit the quantity of long-acting opioids?
☐

Yes

☐

No

a) If “Yes,” what is your maximum daily limit in terms of number of units (i.e. tablets,
capsules)?
☐ 2 units/day
☐ 3 units/day
b) If “Yes,” what is your maximum days supply per prescription limitation?
☐ 30 day supply
☐ 90 day supply
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☐ Other, please explain

3. Do you currently have edits in place to monitor opioids and benzodiazepines being used
concurrently?
☐

Yes

☐

No

If “Yes,” please explain.

E. MORPHINE EQUIVALENT DAILY DOSE (MEDD)
1. Have you set recommended maximum morphine equivalent daily dose measures?
☐

Yes

☐

No

If “Yes,” what is your maximum morphine equivalent daily dose limit in milligrams?
mg per day
If “No,” please explain the measure or program you utilize.

2. Do you provide information to your prescribers on how to calculate the morphine
equivalent daily dosage?
☐

Yes

☐

No

If “Yes,” how is the information disseminated?
☐
☐
☐
☐

Website
Provider notice
Educational seminar
Other, please explain.
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3. Do you have an algorithm in your POS system that alerts the pharmacy provider that the
morphine equivalent daily dose prescribed has been exceeded?
☐

Yes

☐

No

F. BUPRENORPHINE and BUPRENORPHINE/NALOXONE COMBINATIONS
1. Does your agency set total mg per day limits on the use of buprenorphine and
buprenorphine/naloxone combination drugs?
☐

Yes

☐

No

If “Yes,” please specify the total mg/day.
☐
☐
☐
☐

12mg
16 mg
24 mg
Other, please explain

2. What are your limitations on the allowable length of this treatment?
☐
☐
☐
☐

6 months
12 months
No limit
Other, please explain.

3. Do you require that the maximum mg per day allowable be reduced after a set period of time?
☐

Yes

☐

No

a) If “Yes,” what is your reduced (maintenance) dosage?
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☐
☐
☐
☐

8mg
12mg
16mg
Other, please explain.

b) If “Yes,” what are your limitations on the allowable length of the reduced dosage
treatment?
☐
☐
☐
☐

6 months
12 months
No limit
Other, please explain.

4. Do you have at least one preferred buprenorphine/naloxone combination product available on
your PDL?
☐

Yes

☐

No

5. Do you currently have edits in place to monitor opioids being used concurrently with any
buprenorphine drug?
☐

Yes

☐

No

If “Yes,” can the POS pharmacist override the edit?
☐

Yes

☐

No

G. ANTIPSYCHOTICS /STIMULANTS
ANTIPSYCHOTICS
1. Do you have a documented program in place to either manage or monitor the
appropriate use of antipsychotic drugs in children?
☐

Yes

☐

No
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If “Yes,” do you either manage or monitor:
☐ Only children in foster care
☐ All children
☐ Other, please explain

If “Yes,” do you have edits in place to monitor:
☐

Child’s Age ☐

Dosage

☐

Polypharmacy

Please briefly explain the specifics of your antipsychotic monitoring program(s).

If you do not have an antipsychotic monitoring program in place, do you plan on
implementing a program in the future?
☐

Yes

☐

No

If “No,” please explain why you will not be implementing a program to monitor the
appropriate use of antipsychotic drugs in children.

STIMULANTS
2. Do you have any documented restrictions or special program in place to monitor, manage, or
control the use of stimulants?
☐

Yes

☐

No

If “Yes,” is your program limited to:
☐
☐

Children
Adults
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☐

Both

Please briefly explain your program.

IX.

INNOVATIVE PRACTICES
Have you developed any innovative practices during the past year which you have included in
Attachment 6 - Innovative Practices (e.g. Hepatitis C, Cystic Fibrosis, MEDD, Value Based
Purchasing)?
☐

X.

Yes

☐

No

E-PRESCRIBING

1. Does your MMIS or pharmacy vendor have a portal to electronically provide patient drug
history data and pharmacy coverage limitations to a prescriber prior to prescribing upon
inquiry?
☐

Yes

☐

No

a) If “Yes,” do you have a methodology to evaluate the effectiveness of providing drug
information and medication history prior to prescribing?
☐
Yes ☐
No
b) If “Yes,” please explain the evaluation methodology in Attachment 7 – E-Prescribing
Activity Summary.
c) If the answer to (number 1) above is “No,” are you planning to develop this capability?
☐

Yes

☐

No

2. Does your system use the NCPDP Origin Code that indicates the prescription source?
☐

Yes

☐

No

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XI.

MANAGED CARE ORGANIZATIONS (MCOs)
1. Does your state have MCOs?
☐

Yes

☐

No

If “No,” please skip the rest of this section.
2. Is your pharmacy program included in the capitation rate (carved in)?
☐

Yes

☐

No

☐

Partial

If “partial,” please specify the drug categories that are carved out.

3. Does the state set requirements for the MCO’s pharmacy benefit (e.g. same PDL, same
ProDUR/RetroDUR)?
☐

Yes

☐

No

If “Yes,” please check all requirements that apply below:
☐

Formulary Reviews

☐

Same PDL

☐ Same ProDUR ☐

Same RetroDUR

If “Yes,” please briefly explain your policy.

If “No,” do you plan to set standards in the future?
☐

Yes

☐

No

4. Does the state require the MCOs to report their DUR activities?
☐

Yes

☐

No

If “Yes,” please explain your review process.

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If “No,” do you plan to develop a program to have MCOs report their DUR activities in the
future?
☐

Yes

☐

No

If “No,” please explain.

5. Does all of the Medicaid MCOs in your state have a targeted intervention program (i.e.
CMC/Lock In) for the misuse or abuse of controlled substances?
☐

Yes

☐

No

If “No,” please explain.

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XII.

EXECUTIVE SUMMARY - Attachment 8 – Executive Summary

MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT
INSTRUCTIONS: Nomenclature Format for Attachments
States: Please use this standardized format for naming attachments.
ATT#-FFY- State Abbrev-Abbreviated Report name (NO
SPACES!) Example for Arizona: (each state should insert their 2
letter state code) Attachments:

ATT1-201_-AZ-POCCR

(Pharmacy Oral Counseling Compliance Report)

ATT2-201_-AZ-REOS

(RetroDUR Educational Outreach Summary)

ATT3-201_-AZ-SDBA

(Summary of DUR BD Activities)

ATT4-201_-AZ-GDSP

(Generic Drug Substitution Policies)

ATT5-201_-AZ-CSCAM

(Cost Savings/Cost Avoidance Methodology)

ATT6-201_-AZ-IPN

(Innovative Practices Narrative)

ATT7-201_-AZ-EAS

(E-Prescribing Activity Summary)

ATT8-201_-AZ-ES

(Executive Summary)

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I.

EXPLANATION FOR ATTACHMENTS AND TABLES
ATTACHMENT 1 – PHARMACY ORAL COUNSELING COMPLIANCE REPORT
This attachment reports the monitoring of pharmacy compliance with all prospective DUR
requirements performed by the State Medicaid Agency, the State Board of Pharmacy, or other
entity responsible for monitoring pharmacy activities. If the State Medicaid Agency itself
monitors compliance with these requirements, it may provide a survey of a random sample of
pharmacies with regard to compliance with the Omnibus Budget Reduction Act (OBRA) of
1990 prospective DUR requirement. This report details state efforts to monitor pharmacy
compliance with the oral counseling requirement. This attachment should describe in detail
the monitoring efforts that were performed and how effective these efforts were in the fiscal
year reported.
ATTACHMENT 2 – RETROSPECTIVE EDUCATIONAL OUTREACH
SUMMARY
This is a year-end summary report on RetroDUR screening and educational
interventions. The year-end summary reports should be limited to the TOP 10
problems with the largest number of exceptions. The results of RetroDUR
screening and interventions should be included.
ATTACHMENT 3 – SUMMARY OF DUR BOARD ACTIVITIES
This summary should be a brief descriptive report on DUR Board activities during the
fiscal year reported. This summary should:
• Indicate the number of DUR Board meetings held.
• List additions/deletions to DUR Board approved criteria.
a) For prospective DUR, list problem type/drug combinations added or
deleted.
b) For retrospective DUR, list therapeutic categories added or deleted.
• Describe Board policies that establish whether and how results of prospective DUR
screening are used to adjust retrospective DUR screens. Also, describe policies that
establish whether and how results of retrospective DUR screening are used to adjust
prospective DUR screens.
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• Describe DUR Board involvement in the DUR education program (e.g., newsletters,
continuing education, etc.). Also, describe policies adopted to determine mix of
patient or provider specific intervention types (e.g., letters, face-to-face visits,
increased monitoring).

ATTACHMENT 4 – GENERIC DRUG SUBSTITUTION POLICIES
Please report any factors that could affect your generic utilization percentage and
include any relevant documentation.

ATTACHMENT 5 – COST SAVINGS/COST AVOIDANCE METHODOLOGY
Include copy of program evaluations/cost savings estimates prepared by state or contractor
noting methodology used.

ATTACHMENT 6 – INNOVATIVE PRACTICES
Please describe in detailed narrative form any innovative practices that you believe have
improved the administration of your DUR program, the appropriateness of prescription
drug use and/or have helped to control costs (e.g., disease management, academic
detailing, automated prior authorizations, continuing education programs).

ATTACHMENT 7 – E-PRESCRIBING ACTIVITY SUMMARY
Please describe all development and implementation plans/accomplishments in the
area of e- prescribing. Include any evaluation of the effectiveness of this technology
(e.g., number of prescribers e-prescribing, percent e-prescriptions to total
prescriptions, relative cost savings).

ATTACHMENT 8 – EXECUTIVE SUMMARY

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OMB approved # 0938-0659
TABLE 1 – TOP DRUG CLAIMS DATA REVIEWED BY THE DUR BOARD
List the requested data in each category in the chart below.
Column 1- Top 10 Prior Authorization (PA) Requests by Drug Name
Column 2- Top 10 PA Requests by Drug Class
Column 3- Top 5 Claim Denial Reasons other than eligibility (i.e. Quantity Limits, Early Refill, PA,
Therapeutic Duplications, Age Edits)
Column 4- Top 10 Drug Names by Amount Paid
Column 5- From Data in column 4, Determine the Percentage of Total Drug Spend
Column 6- Top 10 Drug Names by Claim Count
Column 7- From Data in Column 6, Determine the Percentage of Total Claims
Top 10
PA Requests
By Drug Name

Top 10
PA Requests
By Drug Class

Top 5 Claim Denial
Reasons (i.e. QL,
Early Refill, PA,
Duplication)

Top 10 Drug
Names by
Amount Paid

% of Total Spent
for Drugs by
Amount Paid

Top 10 Drug
Names by Claim
Count

Drugs By Claim
Count % of Total
Claims

xxxxxxxxxxx
xxxxxxxxxxx
xxxxxxxxxxx
xxxxxxxxxxx
xxxxxxxxxxx

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TABLE 2 – GENERIC UTILIZATION DATA
Please provide the following utilization data for this DUR reporting period
for all covered outpatient drugs paid. Exclude Third Party Liability.
(COMPLETE TABLE 2)
Computation Instructions:
KEY:
Single-Source (S) - Drugs having an FDA New Drug Application (NDA), and
there are no generic alternatives available on the market.
Non-Innovator Multiple-Source (N) - Drugs that have an FDA Abbreviated New Drug
Application (ANDA), and there exists generic alternatives on the market.
Innovator Multiple-Source (I) - Drugs which have an NDA and no longer have patent
exclusivity.

1. Generic Utilization Percentage: To determine the generic utilization
percentage of all covered outpatient drugs paid during this reporting
period, use the following formula:
N ÷ (S + N + I) × 100 = Generic Utilization Percentage
2. Generic Expenditures Percentage of Total Drug Expenditures: To determine
the generic expenditure percentage (rounded to the nearest $1000) for all
covered outpatient drugs for this reporting period use the following formula:
$N ÷ ($S + $N + $I) × 100 = Generic Expenditure Percentage
TABLE 2: GENERIC DRUG UTILIZATION
Single Source (S) Drugs

Non-Innovator (N) Drugs

Innovator Multi-Source (I) Drugs

Total Number of
Claims
Total
Reimbursement
Amount Less
Co-Pay

CMS has developed an extract file from the Medicaid Drug Rebate Program Drug Product Data
File identifying each NDC along with sourcing status of each drug: S, N, or I (see Key below). This
file will be made available from CMS to facilitate consistent reporting across States with this data
request.

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