A-2.3. Definitions

  • Board: The Drug Utilization Review Board
  • Clinical prior authorization: Prospective-DUR prior authorization tool used at the point of sale based on evidence-based clinical criteria and nationally recognized peer-reviewed information.
  • Conflict of interest: A situation that arises wherein a board member or any family member or relative has a financial relationship with an entity, ownership or financial interest with an entity, or any other interest where the member is in a position to derive a personal benefit from action or decisions made in their professional capacity, with an entity.
  • DUR: Drug Utilization Review is a process required by federal law in the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) to assure that prescriptions for covered outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical results.
  • Drug Utilization Review Program: Program operated by the Vendor Drug Program to improve the quality of pharmaceutical care under Medicaid consisting of prospective drug review, retrospective drug use review, and educational program.  
  • Educational interventions: Method of educating providers on identified common drug therapy problems needing improved prescribing or dispensing practices, usually identified as part of the retrospective DUR reviews.
  • Entity: Includes an individual, a corporation, organization, business trust, estate, trust, partnership, association, and any other legal entity that may have business come before the DUR Board or before the Medicaid Vendor Drug Program. The term includes:
    • (A) a pharmaceutical manufacturer or labeler with a product on the Texas Drug Code Index and any other entity HHSC has engaged to assist in developing the preferred drug list or in administering of the DUR Program, and
    • (B) an affiliate or associate of such an entity.
  • Family member or relative: An individual who is related within the third degree by consanguinity or within the second degree by affinity, as defined by the Government Code, Chapter 573, Subchapter B (concerning Relationships by Consanguinity or by Affinity).
  • Financial relationship: A written or oral agreement between a board member and an entity that results in the payment of federally reportable income to the board member (i.e., income reported on IRS Form 1099 or Form W-2).
  • HHS: Health and Human Services System
  • HHSC: Health and Human Services Commission
  • Other interest: Involvement in the affairs of an entity that impairs or may be perceived as impairing a board member's independence of judgment regarding the board member's performance of duties for the DUR Board.
  • Ownership or financial interest: An equity interest in an entity where a board member exercises control over the selection of investments and any other financial interest whose value cannot be readily determined through reference to public records.
  • Texas Medicaid Preferred Drug List (PDL): List of covered outpatient drugs reviewed by Board for their efficaciousness, clinical significance, cost-effectiveness, and safety for patients and recommended as either preferred or non-preferred. PDL is a subset of products on the Texas Medicaid formulary.
  • Retrospective DUR: Review of prescription drug claims data to identify patterns of prescribing.