Retrospective Drug Use Review Process

PURPOSE: This rule establishes the MO HealthNet Division (MHD) process by which the Drug Utilization Review Board is established as required by Section 4401 of P.L. 101-508 (Omnibus Budget Reconciliation Act of 1990) and by section 208.175, RSMo. (1) Drug Utilization Review (DUR) Board. This rule establishes a MO HealthNet DUR Board in the Department of Social Services, MO HealthNet Division. The board shall be composed as specified in section 208.175, RSMo. (2) The board members shall elect a chairperson. (3) The DUR Board shall meet at least once every ninety (90) days. A quorum of two-thirds (2/3) of the total members, including no fewer than three (3) physicians and three (3) pharmacists, is required for the board to act in its official capacity. (4) Members shall serve four- (4-) year terms, except the terms of the original members, two (2) shall be appointed for a term of two (2) years, three (3) shall be appointed for a term of three (3) years, and three (3) shall be appointed for a term of four (4) years. Members may be reappointed, provided that minimum qualifications for membership continue to be met. Nominations shall be referred for final appointment by the governor subject to advice and consent of the senate. As vacancies occur, the DUR Board shall solicit and select a slate of nominees. (5) The members of the DUR Board shall receive no compensation for their services other than reasonable expenses incurred in performing their official duties. (6) The DUR Board shall hold a public hearing during which MHD shall make recommendations to the board. (7) MHD shall make available any changes recommended by the DUR Board via the approved minutes of the DUR Board meeting in a timely fashion, at least thirty (30) days before the implementation of the recommendations. (8) The DUR Board shall provide, either directly or through contracts between MHD and accredited health-care schools, state medical societies, or state pharmacist associations or societies, or other appropriate organizations, for educational outreach programs as required by P.L. 101-508, Section 4401, to educate practitioners on common drug therapy problems and improve prescribing and dispensing practices. This outreach shall include an educational newsletter to MHD providers including appropriate drug use guidelines and MHD utilization statistics. The board activities shall consist of— (A) Establishment and implementation of medical standards and criteria for the prospective and retrospective DUR program; (B) Development, selection, application, and assessment of educational interventions for physicians, pharmacists, and participants that improve care; and (C) Administration of the Drug Prior Authorization Process as outlined in 13 CSR 70-20.200. (9) As specified by P.L. 101-508, Section 4401, the DUR Board shall monitor drug use and prescribing and dispensing practices in the MHD program. This monitoring shall include reviewing and refining therapeutic criteria modules used in retrospective and prospective DUR and overseeing retrospective DUR intervention methods. (10) The DUR Board shall advise MHD regarding all activities associated with the DUR process, including identifying types of intervention methods ranging from letters to physicians and pharmacists, face-to-face education, and educational symposiums for targeted providers. The board shall provide educational support and guidance as needed by the review committees. The review committees, in turn, shall report intervention results and make recommendations to the board based on these results. (11) Patterns of inappropriate or aberrant prescribing or dispensing shall be identified and referred to the board to formulate targeted education. (12) Agency Responsibility Regarding Confidentiality of Information. All information concerning applicants and MHD participants shall be confidential, and any disclosure of this information shall be restricted to purposes directly related to the administration of the medical assistance program. Purposes directly related to administration of the medical assistance program include— (A) Establishing eligibility; (B) Determining the amount of medical assistance; (C) Providing services for recipients; and (D) Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the program. AUTHORITY: sections 208.175, 208.201, and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2024.* Original rule filed Dec. 14, 1992, effective June 7, 1993. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed Sept. 16, 2020, effective March 30, 2021. Amended: Filed Oct. 23, 2024, effective May 30, 2025. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.175, RSMo 1992, amended 1993, 2011, 2014; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.