Maryland Medicaid Pharmacy Program

Drug Utilization Review

The Maryland Medicaid Pharmacy Program has a number of measures in place to insure appropriate, medically necessary and safe use of medications by recipients. All pharmacy claims are reviewed individually before the drugs are dispensed (Prospective Drug Utilization Review or ProDUR). Aggregated claims data from all recipients is analyzed to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care (Retrospective Drug Utilization Review or RDUR).

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  • Reviewing the available medical history including the patient's age, sex, diagnoses or drug allergies.

The ProDUR messages indicate to the pharmacist when intervention, consultation with the prescriber, or counseling of the patient should be considered.

As part of Retrospective Drug Utilization Review (RDUR), recipients are identified who may be at risk for adverse outcomes due to potential drug therapy problems, such as drug-drug interactions, overutilization, drug-disease interactions, non-adherence and therapeutic duplication. Their drug history profiles are reviewed for potential drug therapy concerns. Educational intervention letter are then sent to prescribers and pharmacy providers that are non-confrontational and designed to help providers better manage patients' drug therapy.

The RDUR Program is also responsible for identifying patients who may be receiving excessive quantities of controlled substances. Patients can be identified who utilize multiple pharmacies, multiple prescribers, or both, and whose profiles show patterns of abuse and/or gross overuse of controlled drugs. Both providers and patients are sent intervention letters. If excessive utilization of controlled drugs is not reduced, the patient may be included in the Corrective Managed Care Program and restricted to a single pharmacy.

The Pharmacy Program is advised by the Maryland Drug Utilization Review Board, which meets quarterly and is made up of volunteer physicians and pharmacists. Based on their analysis of patterns of drug use among Medicaid recipients and their professional experience, the Board recommends policies, medical criteria, and programs to guide prescribers, providers and patients.