Drug Utilization Review (DUR) Board program
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Governs the Illinois Department of Healthcare and Family Services' Drug Utilization Review program and DUR Board activities affecting Medicaid pharmacy benefits, including prospective and retrospective DUR, educational initiatives, and prior authorization interactions.
No material clinical or coverage changes in this revision.
Provider Actions, Prior Authorization, and Claims Edits
Use prior approval to override claims edits
HFS may override claims-processing edits on a case-by-case basis by granting a drug prior approval; prior approval status can be searched at Drug Search (ilpriorauth.com).
Claims edits and prior authorization controls
HFS implements claims processing edits and prior authorization criteria that can alter utilization and may require provider action to obtain coverage or dispense medication.
- Edits are implemented to prevent inappropriate utilization (e.g., therapeutic duplication, excessive duration, unsupported off‑label use).
- When an edit is in place, prior authorization may be needed to proceed and can be used to override the edit on a case‑by‑case basis.
Perform prospective DUR, counseling, and provide documentation/education
Pharmacists must perform prospective DUR at the point of sale, counsel clients according to state standards, and provide or refer to patient‑ or drug‑specific information when appropriate; educational materials and DUR recommendations are posted on the HFS DUR webpage.
- Prospective DUR screens for therapeutic duplication, contraindications, interactions, incorrect doses or durations, allergy issues, and misuse.
- Patient‑specific or drug‑specific information and recommendations may be communicated verbally or in writing as part of prior authorization or educational interventions.
Claims edits can result in denials without prior approval
Claims processing edits HFS implements to prevent inappropriate utilization (therapeutic duplication, excessive duration, unsupported off‑label use, unnecessary fills) can cause claim denials unless an override is obtained via the drug prior approval system.
- Edits are applied to drug claims to prevent inappropriate utilization and can result in denial if not overridden.
- Providers should request prior approval when an edit blocks a claim to avoid denial.
Program Background
The Illinois Department of Healthcare and Family Services maintains a Drug Utilization Review (DUR) program to ensure appropriate medication use for Medicaid recipients through both prospective and retrospective reviews. Federal regulation (eCFR § 42 CFR 456.703) requires state Medicaid programs to conduct these reviews and maintain an educational program to support safe, effective prescribing and dispensing. Prospective DUR occurs at point-of-sale, where pharmacists screen for issues such as therapeutic duplication, drug–disease contraindications, drug–drug interactions, incorrect doses or durations, drug–allergy interactions, and clinical abuse/misuse, and then counsel clients according to state standards. Retrospective DUR periodically evaluates drug claims and related records to identify problematic utilization patterns (for example, fraud, over- or underutilization, inappropriate durations, unsupported off-label use, and therapeutic duplication) and to inform edits and educational interventions.
Definitions
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