PURPOSE: This rule establishes the division process by which the Drug Use Review Board will be established as required by Section 4401 of P.L. 101-508 (Omnibus Budget Reconciliation Act of 1990) and by section 208.175, RSMo.

1. (1) Drug Use Review (DUR) Board. This rule establishes a Medicaid DUR board in the Department of Social Services, Division of Medical Services. The board shall be composed as specified in section 208.175, RSMo.

2. (2) Members of the DUR board must have the following minimum qualifications:

   1. (A) Must be licensed by Missouri, with that license in active status and in good standing; and

   2. (B) Must have recognized knowledge and expertise in one (1) or more of the following:

      1. 1. The clinically appropriate prescribing

of covered outpatient drugs;

1. 2. The clinically appropriate dispensing

and monitoring of covered outpatient drugs;

1. 3. Drug use review, evaluation and inter-

vention; or

1. 4. Medical quality assurance.

1. (3) A chairperson shall be elected by the board members.
2. (4) The board shall meet at least once every ninety (90) days. A quorum of two-thirds (2/3) of the total members, including no fewer than two (2) physicians or two (2) pharmacists, is required for the board to act in its official capacity.
3. (5) Members shall serve four (4)-year terms, except the terms of the original members, two
4. (2) shall be appointed for a term of two (2) years, three (3) shall be appointed for a term of three (3) years, and three (3) shall be appointed for a term of four (4) years. Members may be reappointed, provided that minimum qualifications for membership continue to be met. Nominations shall be referred for final appointment by the governor subject to advice and consent of the senate. As vacancies occur, the DUR board shall solicit and select a slate of nominees.
5. (6) The members of the board shall receive no compensation for their services other than reasonable expenses actually incurred in the performance of their official duties.
6. (7) The DUR board shall provide, either directly or through contracts between the Division of Medical Services and accredited health care schools, state medical societies or state pharmacist associations or societies or other appropriate organizations, provide for educational outreach programs as required by P.L. 101-508, Section 4401, to educate practitioners on common drug therapy problems with the aim of improving, prescribing and dispensing practices. This outreach shall include an educational newsletter to Missouri Medicaid providers including appropriate drug use guidelines and Medicaid utilization statistics.
7. (8) As specified by P.L. 101-508, Section 4401, the DUR board shall monitor drug use, and prescribing and dispensing practices in the Medicaid program. This monitoring shall include reviewing and refining therapeutic criteria modules used in both retrospective and prospective DUR, as well as overseeing retrospective DUR intervention methods used.
8. (9) The DUR board shall advise the Department of Social Services regarding all activities associated with the DUR process, including identifying types of intervention methods to be initiated by the review committees, ranging from letters to physicians and pharmacists, face-to-face education and educational symposiums for targeted providers. The board shall provide educational support and guidance as needed by the review committees. The review committees, in turn, shall report intervention results and make recommendations based on these results to the board.
9. (10) The DUR board shall review and research recommendations from the Prior Authorization Committee, as established by 13 CSR 70-20.200, regarding the advisability of implementing or removing prior authorization requirements for a drug or class of drugs, and make a recommendation to the Department of Social Services.
10. (11) Specialized DUR Committees. Subject to appropriation, up to six (6) regional review committees may be appointed by the director of the Department of Social Services for the areas surrounding St. Louis, Kansas City, Springfield, Cape Girardeau, Kirksville and Columbia. Other specialized review committees may be formed at the discretion of the Department of Social Services. Members of the review committees shall be physicians and pharmacists appointed by the DUR board, totaling no fewer than five (5) and no more than ten (10) members per committee. A quorum of fifty-one percent (51%) of the total members must be present to conduct business. Regional committee members shall have the same minimum qualifications as required for the DUR board members. Regional committee meetings shall be held every other month. The members of each committee shall elect a chairperson, who shall serve as an ex officio member of the DUR board. Committee members shall receive no compensation other than reasonable expenses actually incurred in the performance of their official duties.
11. (12) The regional review committees shall conduct patient profile reviews, including opening and closing of cases at the committee meetings. Interventions shall be initiated and follow-up reviews performed by the regional committees. Patterns of inappropriate or aberrant prescribing or dispensing shall be identified and referred to the board in order for targeted education to be formulated.

12. (13) Agency Responsibility Regarding Confidentiality of Information. All information concerning applicants and recipients of medical services shall be confidential and any disclosure of this information shall be restricted to purposes directly related to the administration of the medical assistance program. Purposes directly related to administration of the medical assistance program include:

    1. (A) Establishing eligibility;
    2. (B) Determining the amount of medical assistance;
    3. (C) Providing services for recipients; and
    4. (D) Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the program.

13. (14) Provider Responsibility Regarding Confidentiality of Information. All information concerning applicants and recipients of medical services shall be confidential. Any disclosure of this information shall be restricted to purposes directly related to the treatment of the patient and promotion of improved quality of care. The confidential information includes:

    1. (A) Names and addresses;
    2. (B) Social Security number;
    3. (C) Medical services provided;
    4. (D) Social and economic conditions or circumstances;
    5. (E) Medical data, including diagnosis and past history of disease or disability;
    6. (F) Any information received for verifying income eligibility; and
    7. (G) Any information received in connection with the identification of legally liable third-party resources.

AUTHORITY: sections 208.153, RSMo Supp. 1991, 208.175, RSMo Supp. 1993 and 208.201, RSMo Supp. 1987. Original rule filed Dec. 14, 1992, effective June 7, 1993.

*Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; 208.175, RSMo 1992, amended 1993; and 208.201, RSMo 1987.