Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 16 - PHARMACY SERVICES
Section 471-16-010 - DRUG UTILIZATION REVIEW
Current through March 20, 2024
The Department is authorized by federal statute to conduct a Drug Utilization Review program. The Drug Utilization Review program consists of prospective drug review, retrospective drug review, the application of explicit predetermined standards, and an educational program. The purpose of the Drug Utilization Review program is to improve the quality of pharmaceutical care by ensuring prescriptions are appropriate and medically necessary and not likely to result in adverse medical results.
010.01 DRUG UTILIZATION REVIEW BOARD. The Department or the Department's contractor utilizes a Drug Utilization Review Board to review and analyze available clinical and economic data. The Drug Utilization Review Board reviews and makes recommendations based on predetermined standards submitted to them by the Department or the Department's contractor and, in concert with retrospective review of claims data, makes recommendations for educational interventions, prospective Drug Utilization Review, and the prior authorization process.
010.02 REVIEW FOR PRIOR AUTHORIZATION RECOMMENDATION. The Drug Use Review Board will, upon the Department's request, review drugs or classes of drugs and make recommendations to the Department regarding drugs or classes of drugs for prior authorization. The Department makes the final decision on which drugs or classes of drugs will require prior authorization. For those drugs which will require prior authorization, the Drug utilization Review Board will develop and recommend prior authorization criteria to the Department. The Department may accept, reject, or modify the recommended criteria. The Department will communicate information related to prior authorization criteria on the Nebraska Medicaid Pharmacy Program website. The Drug Utilization Review Board will review existing prior authorization criteria annually.
010.03 MANUFACTURER REQUESTS FOR DRUG REVIEW. The manufacturer or any interested party may request a drug or class of drugs on prior authorization be placed on the agenda of a Drug Utilization Review board meeting, but no drug or class of drugs will be placed on the Drug Utilization Review agenda more than once every 12 months without the consent of the Drug Utilization Review director, in consultation with the Department's Pharmacy Consultant. The manufacturer of the drug may request the Drug Utilization Review director waive the 30-day notification rule when asking to have its product placed on the agenda.
