AZBH

"22. QUALITY MANAGEMENT/UTLIZATION MANAGEMENT (QM/UM)...
ADHS and its subcontracted RBHAs shall comply with the following requirements related to quality management and
utilization review: ...
l. Ensure review of prescribing patterns and drug utilization." Arizona Behavioral Contract, page 24.

IABH

"E. Oversight of the Utilization of Psychotropic Medications (Proposal Section 7A.2.14)

In cooperation with the Iowa's Drug Utilization Review (DUR) Commission, MBC of Iowa will:
* Monitor for potential changes in the overall utilization of psychotropic medications by those enrolled in the Iowa Plan (reference 5.15.12),
* Analyze utilization patterns on a quarterly basis (reference 6.4.2),
* Study the utilization of psychotropic medication (reference 6.4.2),
* Initiate a pilot project reviewing the appropriateness of PCP prescriptions of psychotropic medications,
* Analyze bi-annually a list of enrollees who are on two (2) or more separate medications of the same classification, and
* Monitor prescribing profiles of network and non-network physicians.
* Assess the appropriateness of medications prescribed for individual Iowa Plan enrollees (reference 6.4.2)

MBC of Iowa network providers will be required to coordinate and communicate with PCPs regarding Iowa Plan enrollees' medications (Iowa Plan enrollees must sign a release of information allowing network providers to communicate with PCPs). This coordination will be monitored through the care management process and through annual on-site retrospective review of medical records.

MBC of Iowa, with input from the Iowa Drug Utilization Review Commission, providers and PCPs, will include in the
provider manual requirements to screen for any known drug allergies, other medications they are currently taking,
changes in medications, adverse reactions to screening will be required at the onset of treatment and regularly
throughout treatment.

MBC of Iowa will detect and address non-compliance, under-utilization and misuse of medications by completing
treatment record reviews; monitoring provider incidents filed by care management staff; analyzing, on a monthly
basis, the data tape reflecting all claims paid on behalf of Iowa Plan enrollees for psychotropic medication for
last two weeks. Care Teams will immediately staff any cases of possible under-utilization or misuse of medications
with the MBC of Iowa Medical Director." Iowa Behavioral Health Contract, pages 59-60.

MD

"10.09.67.04...
D. Drug Formulary...
(4) To ensure that its formulary drugs are medically appropriate, safe, and efficacious, an MCO shall:
(a) Subject its formulary to a drug utilization review program that is:
  (i) Established by the MCO,
  (ii) Approved by the Department, and
  (iii) Coordinated with the drug utilization review program of the Specialty Mental Health Services delivery system; and
(b) Submit its formulary for the review and approval of the Department, based upon the standards set forth in this
regulation." Maryland COMAR 10.09.67.04.

NJ

"10.14.
H. The contractor shall establish and maintain a Drug Utilization Review (DUR) program which satisfies the minimum requirements for prospective and retrospective DUR program." New Jersey Contract, pages 57-59.

"ARTICLE 16
MONITORING AND EVALUATION...
16.14 The contractor shall establish and maintain a drug utilization review (DUR) program which satisfies the minimum requirements for prospective and retrospective DUR as described in 1927(g) of the Social Security Act, amended by the Omnibus Budget Reconciliation Act (OBRA) of 1990.
A. DUR standards shall encourage proper drug utilization by ensuring maximum compliance, minimizing potential
fraud and abuse, and taking into consideration both the quality and cost of the pharmacy benefit.
B. The contractor must implement a claims adjudication system, preferably on-line, which shall include a prospective review of drug utilization.
C. The prospective and retrospective DUR standards established by the contractor shall be consistent with those same standards established by the Medicaid Drug Utilization Review Board." New Jersey Contract, pages 84-90.

NM

"2.D.14 Pharmacy Services...
2.D.14.a Drug Utilization Review Program. The CONTRACTOR shall maintain written policies and procedures governing its drug utilization review (DUR) program, in compliance with any applicable Federal Medicaid law." New Mexico Contract, page 40.

PA

"F. IN-PLAN SERVICES
4. Drug Utilization Review
The HMO must have written policies and procedures to adhere to the Drug Utilization Review (DUR) Program approved by the Department. This system will be based on federal statute/regulation citation Section 4401 (g) of OBRA '90 and 42 CFR 4456. As part of this, the HMO must assure that prescriptions for outpatient drugs are appropriate, medically necessary, and are not likely to result in adverse medical results. The HMO must also have a Department-approved education program aimed at all the recipients." Pennsylvania RFP, pages 37-47.

"H. COORDINATION WITH OUT-OF-PLAN SERVICES...
9. Behavioral Health Services...
* The HealthChoices HMO must establish written policies and procedures to collaborate with the behavioral health
contractor in adhering to a drug utilization review (DUR) program approved by the Department." Pennsylvania RFP,
pages 51-59.

PABH

"b. Coordination (Part IV, Section D.2)...
4) Describe any processes planned to monitor HMO and MCO practitioners in their coordinated approach to the selection and the use of drugs in treating members." Pennsylvania Behavioral Health RFP, page 22.

"c. The MCO must establish processes to coordinate in-plan service delivery with services delivered outside the scope of services covered by the MCO: ...
2) Pharmacy Services
a). The HMO may only restrict prescriptions or pharmacy services of a MCO if one of the following exceptions is demonstrated:
  i) The drug prescribed is not related to the treatment of substance abuse/dependency/addiction or mental illness and any side effects of psychopharmacological agents. Those drugs are to be prescribed by the HMO's PCP or specialists in the member's physical care health network.
  ii) The prescribed drug does not conform to standard rules of the pharmacy plan; e.g., use of generic or cost effective alternative(s), purchases from certain pharmacies, and quantity limited to a 30 day supply.
  iii) The drug is prescribed by a behavioral health provider identified as not having a signed provider agreement with the behavioral health contractor. The behavioral health contractor will be required to provide the HealthChoices HMO with their initial provider networks and then provide on a monthly basis, changes including terminations and additions.
  iv) The prescription has been identified as an instance or fraud, abuse, gross overuse, or is contraindicated
because of potential interaction with other medications.

b) The MCO must develop and maintain written agreements with each Health Choices HMO regarding the interaction
and coordination of pharmacy services provided to members of the Health Choices program. The written agreements
must include, but are not limited to:
  i) CMO representation on the HMO's panel of physicians and other clinicians selecting the HMO formulary;
  ii) Procedures for monitoring behavioral health pharmacy services provided by the HMO;
  iii) Procedures for notifying each other of all prescriptions, and when deemed advisable, consultation between practitioners before prescribing medication, and sharing complete, up-to-date medication records;
  iv) Procedures which govern reimbursement by the MCO to the HMO for clozapine and the timely resolution of any
disputes which arise from the payment or use of pharmaceuticals (e.g., use of anti-convulsant medication as a mood
stabilizer) including a mechanism for timely impartial mediation when resolution between the HMO and MCO does not
occur;
  v) Procedures for sharing independently developed quality assurance/utilization management information related to pharmacy services, as applicable.

c) The MCO must establish written policies and procedures to collaborate with HealthChoices HMOs in adhering to a drug utilization review (DUR) program approved by the Department. This system is based on federal statute/regulations [Section 4401 (g) of OBRA 1990, Section 4.26, guidelines 1927 (g), 42 CFR 456].

In addition, the MCO, in collaboration with the HealthChoices HMO, must identify and reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and members associated with specific drugs. Areas for particular attention include potential and actual adverse drug reactions; therapeutic appropriateness; over and under drug use; appropriate use of generic products; therapeutic duplication; drug/disease contraindications; drug to drug interactions; incorrect drug dosage or duration of treatment; drug allergy reactions; and clinical abuse/misuse." Pennsylvania Behavioral Health RFP,
page 51-53.