Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 27 - Department of Medical Services
Rule 016.27.20-005 - SPA # 2019-002, Section 1004 of the SUPPORT Act

State/Territory:

ARKANSAS

Citation

1927(g)(2)(C) 42 CFR 456.709(b)

F.2. The DUR program assesses data on drug use against explicit predetermined standards including but not limited to monitoring for:

-Therapeutic appropriateness

-Overutilization and underutilization

-Appropriate use of generic products

-Therapeutic duplication

-Drug-disease contraindications

-Drug-drug interactions

-Incorrect drug dosage/duration of drug treatment

-Clinical abuse/misuse

1927(g)(2)(D) 42 CFR 456.711

3. The DUR program through its State DUR Board, using data provided by the Board, provides active and ongoing educational outreach programs to educate practitioners on common drug therapy problems to improve prescribing and dispensing practices.

1927(g)(3)(A) 42 CFR 456.716(a)

G.1. The DUR program has established a State DUR Board either:

X Directly, or

__Under contract with a private organization

1927(g)(3)(B) 42 FR 456.716 (A) and (B)

2. The DUR Board membership includes health professionals (at least 1/3 but no more than fifty-one percent (51%) licensed and actively practicing physicians and at least 1/3 licensed and actively practicing pharmacists) with knowledge and experience in one or more of the following:

-Clinically appropriate prescribing of covered outpatient drugs.

-Clinically appropriate dispensing and monitoring of covered outpatient drugs.

-Drug use review, evaluation and intervention.

-Medical quality assurance.

1927(g)(3)(C) 42 CFR 456.716(d)

3. The activities of the DUR Board include:

-Retrospective DUR,

-Application of Standards as defined in section 1927(g)(2)(C), and

-Ongoing interventions for physicians and pharmacists targeted toward therapy problems or individuals identified in the course of retrospective DUR.

1927(g)(3)(C) 42 CFR 456.711(a)-(d)

G.4. The interventions include in appropriate instances: -Information dissemination -Written, oral, and electronic reminders -Face-to-Face discussions -Intensified monitoring/review of prescribers/dispensers

P.L. 115-271 Section 1004 of the SUPPORT Act

H.1. The DUR program meets the requirements of Section 1004 of the SUPPORT Act for substance use-disorder prevention that promotes opioid recovery and treatment. Opioid claim review limitations for initial and subsequent refills require prospective safety edits and comprehensive retrospective claims review processes.

a) Prospective point-of-sale safety edits

* Therapeutic duplication edit

* Maximum daily quantity edit

* Maximum monthly quantity edit

* Morphine Milligram Equivalent edit

* Refill too soon logic

* Age edit

* Maximum days' supply edits for treatment naïve and treatment experienced

b) Retrospective claims review

* Morphine Milligram Equivalent review per recipient and prescriber

* Concurrent opioid and benzodiazepine usage prompts prescriber or pharmacy provider notification by letter

* Concurrent opioid and antipsychotic medication usage prompts prescriber or pharmacy provider notification by letter

* Review opioid use in adolescents

* Review prescribing and dispensing patterns on opioid claims

* Retrospective reviews on opioid prescriptions exceeding these above limitations on an ongoing basis

Citation

H.2. Program to monitor antipsychotic medication use by children

a) Prospective point-of-sale edits

* Age edits for recipients < 18 years old

* Therapeutic duplication edit

* Maximum dose edit

* Antipsychotic medication usage in children including those in foster care are monitored in monthly reports by a staff psychiatrist

* Routine metabolic labs required

b) Retrospective claims review

* Monitor antipsychotic use patterns in children including foster care

* Doses of antipsychotic medications monitored H.3. Fraud and Abuse Identification

a) Lock-in program for recipients identified by Retrospective DUR for possible abuse or misuse of controlled substances

b) Prescriber and pharmacy provider patterns of misuse/overprescribing

* Identified by Retrospective DUR

* Identified by contracted auditor(s)

c) Prescription Drug Monitoring programs enable prescribers and pharmacy providers to search the PDMP for monitoring narcotic use behavior including access to other states

1927(g)(3)(D) 42 CFR 456.712(A) and (B)

I. The State assures that it will prepare and submit an X

annual report to the Secretary, which incorporates a report from the State DUR Board, and that the State will adhere to the plans, steps, procedures as described in the report.

1927(h)(1) 42 CFR 456.7221927(g)(2)(A)(i)

J.1. The State establishes, as its principal means of processing claims for covered outpatient drugs under this title, a point-of-sale electronic claims management system to perform on-line:

-real time eligibility verification

-claims data capture

-adjudication of claims

-assistance to pharmacists, etc. applying for and

receiving payment.

42 FR 456.705(b)

_ 2. Prospective DUR is performed using an electronic point of sale drug claims processing system.

1927(j)(2) 42 CFR 456.703(c)

K. Hospitals which dispense covered outpatient drugs are exempted from the drug utilization review requirements of this section when facilities use drug formulary systems and bill the Medicaid program no more than the hospital's purchasing cost for such covered outpatient drugs.