9.2 Prospective Drug Utilization Review

9.2 Prospective Drug Utilization Review

Quick Answer: Prospective DUR (drug utilization review / drug regimen review) is real-time evaluation of a prescription before dispensing. Illinois § 1330.700 requires a prospective drug regimen review or drug utilization evaluation upon receipt of every new or refill prescription. The Act’s definition of drug regimen review (225 ILCS 85/3(y); mirrored in 1330.10) lists the clinical screens: allergies, contraindications, dose/duration/route, directions, adverse reactions, interactions, therapeutic duplication, utilization, and abuse/misuse. OBRA ’90 is the federal Medicaid floor; Illinois expectations apply more broadly. Clinical conflict resolution is pharmacist work—technicians escalate, they do not clear clinical alerts. When problems arise: assess, contact the prescriber if needed, refuse if necessary, counsel, document.

If counseling is how you communicate safety, prospective DUR is how you detect safety problems before the bag leaves the counter. NABP Competency Area 2.5 (public health quality/safety) and Area 2.3 (counseling) both feed off this skill.

Prospective vs. Retrospective DUR

Do not confuse “retrospective” with casually noticing an error after the patient already took the wrong drug at home—that is error management, not the OBRA-style retrospective DUR program.

Illinois Hook: § 1330.700 + Drug Regimen Review Definition

68 Ill. Adm. Code 1330.700(a) opens with a non-negotiable sentence: upon receipt of a new or refill prescription, a prospective drug regimen review or drug utilization evaluation shall be performed. That means:

• Refills are not exempt from clinical screening
• “The computer already checked it” is not a complete legal answer without pharmacist evaluation of significant issues
• Profile quality (Section 9.1) directly enables lawful DUR

What “drug regimen review” includes

Under 225 ILCS 85/3(y) (restated in 1330.10), drug regimen review means and includes evaluation of prescription drug orders and patient records for:

1. Known allergies
2. Drug or potential therapy contraindications
3. Reasonable dose, duration of use, and route, considering age, gender, and contraindications
4. Reasonable directions for use
5. Potential or actual adverse drug reactions
6. Drug-drug interactions
7. Drug-food interactions
8. Drug-disease contraindications
9. Therapeutic duplication
10. Patient laboratory values when authorized and available
11. Proper utilization (including over- or under-utilization) and optimum therapeutic outcomes
12. Abuse and misuse

Map these to classic OBRA-style screening families used on multistate items:

Credit scores, wholesale costs, and marketing preferences are not DUR categories. Exam writers love a distractor that confuses business metrics with clinical review.

OBRA ’90 Federal Floor + Illinois Overlay

The Omnibus Budget Reconciliation Act of 1990 (OBRA ’90) tied Medicaid participation to:

1. Prospective DUR before dispensing
2. An offer to counsel Medicaid outpatients
3. Patient profiles and retrospective DUR infrastructure

Federal text is often framed as a Medicaid floor. Illinois—through the Practice Act definitions and Part 1330—incorporates prospective review and counseling duties into ordinary pharmacy practice, not merely “if the patient is on Medicaid.” Chapter 3 taught the federal structure; this section is the operational Illinois application:

Decision rule for IL MPJE: If a stem is pure federal history (“What did OBRA require of Medicaid programs?”), answer with ProDUR + counseling offer + profiles/retrospective DUR. If the stem is an Illinois community fill today, do not stop at “Medicaid-only.”

Pharmacist Duty vs. Technician Role

225 ILCS 85/9 bars technicians from patient counseling (beyond the three support tasks), drug regimen review, clinical conflict resolution, ordinary final verification, and reserved HIV PrEP/PEP provision. Translate that into DUR workflow:

Alert fatigue is not a defense. Software supports screening; legal responsibility remains with the pharmacist for significant issues visible from the profile and product.

Action When a Problem Is Found

When prospective DUR identifies a potential or actual problem, the exam-correct sequence is professional, not mechanical:

1. Assess clinical significance using the profile, product knowledge, and available labs.
2. Clarify with the patient when history might be incomplete (OTC NSAID use, alcohol, adherence).
3. Contact the prescriber when therapy change, clarification, or authorization is needed.
4. Counsel the patient on risks, monitoring, and what to do if problems occur—when dispensing proceeds.
5. Refuse to dispense when necessary to protect the patient (e.g., anaphylaxis allergy to the ordered drug without a workable alternative plan).
6. Document the problem, contacts, decisions, and outcome.

Refuse-to-fill is not optional virtue signaling

Corresponding responsibility and public-health quality concepts (later chapters on red flags and controlled substances) rest on the same foundation: you may not knowingly dispense through a resolved clinical danger for convenience, profit, or customer pressure. Documentation should show what was found and why you dispensed, modified, or refused.

Worked vignettes

Vignette 1 — Therapeutic duplication. Profile shows active lisinopril; new Rx for enalapril with no taper plan or specialist note. Pharmacist contacts prescriber, confirms unintentional duplication, cancels one agent, documents. Correct DUR resolution.

Vignette 2 — Interaction. New TMP-SMX for a patient on stable warfarin. Pharmacist assesses bleeding risk, contacts prescriber/clinic about INR plan or alternative antibiotic, counsels patient on bleeding signs if therapy continues, documents. Correct. Auto-override without review is incorrect.

Vignette 3 — Allergy. Amoxicillin ordered; profile lists anaphylaxis to penicillin. Pharmacist does not dispense amoxicillin “because the doctor wrote it.” Contact prescriber for alternative; document refusal if necessary. Correct.

Vignette 4 — Tech override. Senior tech clears a major interaction alert because “the patient has been on both for years.” Without pharmacist clinical evaluation, this is unlawful clinical conflict resolution by a technician—even if historically coincidental concurrent use exists.

Connection to Counseling and Profiles

Prospective DUR and counseling are paired duties in § 1330.700:

• DUR finds the problem
• Counseling (or refusal documentation) communicates safe use
• Profiles store the history that makes both possible

Incomplete allergy fields, missing concurrent meds, and absent pharmacist comments produce blind DUR. Building the profile is not clerical trivia; it is the substrate of Area 2 practice competence.

Common Traps

• Treating DUR as “software only”
• Exempting refills from prospective review despite § 1330.700
• Allowing techs to resolve clinical alerts
• Ignoring significant alerts because the patient is in a hurry
• Answering Illinois practice stems with “Medicaid-only OBRA” limits
• Confusing prospective review with retrospective claims auditing
• Documenting nothing after a major intervention

Study Checklist

1. When is prospective review required in Illinois? → Every new and refill Rx under § 1330.700.
2. Name core drug regimen review elements → allergies, interactions, dose/duration, duplication, disease contraindications, utilization, abuse/misuse, etc.
3. Who resolves clinical conflicts? → Pharmacist, not tech.
4. What is the action sequence? → Assess → clarify/contact → counsel or refuse → document.
5. Federal vs Illinois? → OBRA floor + Illinois broader practice layer.

Section 9.3 turns from “what leaves the pharmacy safely” to “what may come back”—returns, reuse limits, destruction, and diversion risk.