Prospective Drug Use Review Process and Patient Counseling

PURPOSE: This rule establishes provisions for prospective drug use review and patient counseling for MO HealthNet Division (MHD) participants, as required by Section 4401 or Public Law 101-508 (Omnibus Budget Reconciliation Act of 1990) and by section 208.176, RSMo. (1) Prospective Drug Use Review (DUR). This rule establishes a MHD prospective drug use review process within the Department of Social Services, MHD, as specified in section 208.176, RSMo. (2) Electronic Point-of-Sale Review. MHD shall provide for electronic point-of-sale review before each prescription is dispensed to a MHD participant or MHD participant’s responsible party on the date of service. MHD shall provide electronic point-of-sale screening for potential drug therapy problems using the approved clinical modules on the date of service. (3) Electronic Point-of-Sale Review Available for MHD Participants. The pharmacy point of service system will provide the following reviews: (A) Drug Disease Contraindications. 1. Drug (actual) disease precaution. 2. Inferred drug disease precaution; (B) Drug to Drug Interactions; (C) Side Effects. 1. Additive toxicity side effects. 2. Medical condition/additive side effect. 3. Side effect. 4. Drug indicated for the side effect of the previously prescribed drug; (D) Dose Range Checking. 1. High dose alert. 2. Low dose alert; (E) Minimum/Maximum Daily Dose. 1. High dose alert. 2. Low dose alert; (F) Duplicate Therapy Checking. 1. Therapeutic duplication. 2. Ingredient duplication; and (G) Duration of Therapy. 1. Excessive duration alert. (4) MHD Patient Counseling. As part of the prospective DUR program, participating pharmacies shall perform patient counseling according to the standards established by the Board of Pharmacy under 20 CSR 2220-2.190. (5) MHD Patient Profiles. The term “reasonable effort” means that each time a MO HealthNet patient or caregiver presents a prescription, the pharmacist or pharmacist’s designee should request profile information verbally or in writing. Pharmacies must make a reasonable effort to obtain records and maintain patient profiles containing, at a minimum: (A) The name, address, telephone number, date of birth (or age), and gender of the patient; (B) Individual medical history, if significant, including disease states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices; and (C) Pharmacist’s comments relevant to the individual’s drug therapy. (6) Documentation of Offer to Counsel. The pharmacist shall document for each MHD patient’s prescription uniformly whether the offer to counsel was accepted or refused by the patient or the patient’s agent. (7) Provider Responsibility Regarding Confidentiality of MO HealthNet Beneficiary Information. All information concerning applicants and participants of medical services shall be confidential. Any disclosure of this information by the pharmacy provider shall be restricted to purposes directly related to the treatment of the patient and promotion of improved quality of care or conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the program. The confidential information includes— (A) Names and addresses; (B) Social Security number; (C) Medical services provided; (D) Social and economic conditions or circumstances; (E) Medical data, including diagnosis and history of disease or disability; (F) Any information received for verifying income eligibility; and (G) Any information received in connection with the identification of legally liable third-party resources. AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2024.* Original rule filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed Nov. 27, 2019, effective June 30, 2020. Amended: Filed Dec. 17, 2024, effective July 30, 2025. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.