The Texas Vendor drug Program (VDP) implemented prospective and retrospective DUR to ensure appropriate and medically necessary drugs are prescribed to the clients. The Texas Medicaid Drug Utilization Review (DUR) Board’s focus is to promote cost saving initiatives through prospective, Point-of-Sale (POS) interventions. This, along with educational intervention letters, creates opportunity to promote proper pharmaceutical care to Medicaid clients, as well as pharmacy claim reviews by HHSC field staff.
- The percentage net savings for federal fiscal year (FFY) 2015 was 8% of the total expenditure.
- The DUR board conducted 4 meetings for FFY 2015.
Prospective Drug Utilization Review
- Texas implemented 2 point-of-sale, new and revised clinical prior authorization criteria during FFY 2015.
- In addition to clinical and non-preferred prior authorizations, Texas imposed quantity limits and internal prior approval process to some newly added drugs/classes of drugs to help ensure medications are used at appropriate doses for approved indications.
Retrospective Drug Utilization
- Texas contracts with a non-fiscal agent vendor to review patient profiles for new or selected criteria. This is done to identify prescribers who have prescribing practices outside of accepted parameters or clinical guidelines. The outliers are sent educational letters that are approved by the board and include patient profiles and suggestions that include specific performance indicators that enhance treatment management. In 2015 the agency implemented 9 retro-DUR interventions.
- Automated-Refill Policy:
- Refills may only be submitted when requested by the individual. Providers must not bill Medicaid unless the individual has requested the refill – this includes pharmacies that use automated refill systems/programs.
- In FFY 2015 the DUR board addressed many prospective and retrospective interventions, all to improve health and safety of the Medicaid eligible clients as well as ensuring that appropriate cost prevention parameters were in place to maximize limited health resources.