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Medicaid (Title XIX of the Social Security Act)
Covered Outpatient Drugs


Each state must maintain a covered outpatient drug use review program.118  The drug use review program will include:

  • Reviews of drug therapy before prescriptions are dispensed, including screening for potential drug therapy problems.119
  • Establishing standards for pharmacists to use in counseling enrollees, which must include:120
    • A reasonable effort to obtain, record, and maintain name, address, telephone number, date of birth (or age), and gender;
    • Individual history; and
    • Comments relevant to the individual’s drug therapy. 
  • Periodic examination of data to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and enrollees, or associated with specific drugs or groups of drugs.121
  • Assessing data on drug use against explicit predetermined standards.122
  • Establishing a Drug Use Review Board (DUR),123 which will, among other duties:

  • Conduct interventions with physicians and pharmacists, including providing reminders about patient- and/or drug-specific information and suggesting changes in prescribing or dispensing practices, communicated in a manner designed to ensure the privacy of patient-related information.124
  • Re-evaluate interventions after an appropriate period of time to determine if the intervention improved the quality of drug therapy, to evaluate the success of the interventions and to make modifications to interventions as necessary.125

Based on data collected by the activities of the drug use review board and other surveillance and utilization review programs, the Secretary shall periodically update the list of drugs or classes or medical uses that are determined to be subject to clinical abuse or inappropriate use.126



  • 118. Social Security Act § 1903(i)(10)(B), 42 U.S.C. 1396b(i)(10)(B).
  • 119. Social Security Act § 1927(g)(2)(A), 42 U.S.C. 1396r-8(g)(2)(A).
  • 120. Social Security Act § 1927(g)(2)(A)(ii)(II), 42 U.S.C. 1396r-8(g)(2)(A)(ii)(II).
  • 121. Social Security Act § 1927(g)(2)(B), 42 U.S.C. 1396r-8(g)(2)(B).
  • 122. Social Security Act § 1927(g)(2)(C), 42 U.S.C. 1396r-8(g)(2)(C) (Standards must include monitoring for therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, and clinical abuse/misuse).
  • 123. Social Security Act § 1927(g)(3)(A), 42 U.S.C. 1396r-8(g)(3)(A).
  • 124. Social Security Act § 1927(g)(3)(C))(iii), 42 U.S.C. 1396r-8(g)(3)(C)(iii).
  • 125. Social Security Act § 1927(g)(3)(C)(iii), 42 U.S.C. 1396r-8(g)(3)(C)(iii).
  • 126. Social Security Act § 1927(d)(3); 42 U.S.C. 1396r-8(d)(3).