As part of the state-federal partnership in administering Medicaid programs, the Centers for Medicaid and CHIP Services (CMCS) issues technical assistance in the form of letters to State Medicaid Directors (SMD), Center for Medicaid and CHIP Services Informational Bulletins (CIB), Issue Briefs (IB), and Frequently Asked Questions (FAQs) to communicate with states and other stakeholders regarding operational issues related to Medicaid. Drug Utilization Review (DUR) assistance is available to assist state Medicaid agencies in developing, enhancing, implementing, and evaluating regulations and programs to ensure appropriate drug therapy and streamline fraud, misuse and abuse. All Medicaid guidance documents can be found on the federal guidance page. Additionally, notable releases referencing DUR, opioids and prescription drugs can be found below at the following links:
- Report to Congress - Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act: Section 1004 Medicaid Drug Review and Utilization – Federal Fiscal Year 2020 - November 7, 2022
- Final Rule: CMS-2482-F2 Medicaid Program; Delay of Effective Date for Provision Relating to Manufacturer Reporting of Multiple Best Prices Connected to a Value Based Purchasing Arrangement; Delay of Inclusion of Territories in Definition of States and United States - November 19, 2021
- State Health Official Letter: Mandatory Medicaid State Plan Coverage of Medication-Assisted Treatment - December 30, 2020
- Final Rule: CMS-2482-F Medicaid Program - Establishing Minimum Standards in Medicaid State Drug Utilization Review (DUR) and Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements - December 21, 2020
- CIB: State Guidance for Implementation of Medicaid Drug Utilization Review (DUR) provisions included in Section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (P.L. 115-271) - August 5, 2019
- CIB: Medicaid Strategies for Non-Opioid Pharmacologic and Non-Pharmacologic Chronic Pain Management - February 22, 2019
- CIB: State Flexibility to Facilitate Timely Access to Drug Therapy by Expanding the Scope of Pharmacy Practice using Collaborative Practice Agreements, Standing Orders or Other Predetermined Protocols - January 17, 2017
- SMD: Implementation of the Covered Outpatient Drug Final Regulation Provisions Regarding Reimbursement for Covered Outpatient Drugs in the Medicaid Program - February 11, 2016
- CIB: Best Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction - January 28, 2016
42 CFR Subpart K – Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims Section 456.700-456.725 provides the requirements for the DUR program.
Please direct all communications to the CMSDUR@cms.hhs.gov resource mailbox.
Disclaimer: Please note that the information provided on this web page does not bind or obligate the Centers for Medicare and Medicaid Services (CMS). The statements included on this web page are intended to provide information on CMS Medicaid Drug Utilization Review and do not in any way revise or modify the requirements set forth in Section 1927 of the Act, regulations or program releases.
Page last updated on January 25, 2023