§ 369-AA — Definitions

§ 369-aa. Definitions. In this article:\n 1. "Drug utilization review or (DUR)" shall mean the program designed\nto measure and to assess on a retrospective and a prospective basis the\nproper use of outpatient drugs in the medicaid program. Such program\nshall be in addition to the activities of the department with respect to\nthe detection of fraud and abuse in the medical assistance program, the\nsanctioning of providers determined to have engaged in unacceptable\npractices under the medical assistance program, and the recovery of\noverpayments of medical assistance made to providers under the medical\nassistance program.\n 2. "Board" shall mean the drug utilization review board created under\nthis title.\n 3. "Intervention" shall mean a form of communication utilized by the\nDUR board with a prescriber or pharmacist to inform about or to\ninfluence prescribing or dispensing practices.\n 4. "SURS" shall mean the surveillance utilization review system of\nmedicaid.\n 5. "Retrospective DUR" shall mean that part of the drug utilization\nreview program that assesses or measures drug use based on an historical\nreview of drug use data against predetermined and explicit criteria and\nstandards on an ongoing basis with professional input.\n 6. "Prospective DUR" shall mean that part of the drug utilization\nreview program that is to occur before the drug is dispensed that is\ndesigned to screen for potential drug therapy problems based on explicit\nand predetermined standards.\n 7. "Criteria" shall mean those predetermined and explicitly accepted\nelements that are used to measure drug use on an ongoing basis to\ndetermine if the use is appropriate, medically necessary, and not likely\nto result in adverse medical outcomes.\n 8. "Compendia" shall mean those resources widely accepted by the\nmedical profession in the efficacious use of drugs which is based on,\nbut not limited to, these sources: "American Hospital Formulary Services\nDrug Information," "U.S. Pharmacopeia - Drug Information," "AMA Drug\nEvaluations," the peer-reviewed medical literature, and information\nprovided from the manufacturers of drug products.\n 9. "Standards" shall mean the acceptable range of deviation from the\ncriteria that reflects appropriate medical practice and that is tested\non the medicaid recipient database.\n 10. "Therapeutic duplication" shall mean the prescribing and\ndispensing of the same drug or of two or more drugs from the same\ntherapeutic class where overlapping time periods of drug administration\nare involved and where such prescribing or dispensing is not medically\nindicated.\n 11. "Drug-disease contraindications" shall mean the occurrence where\nthe therapeutic effect of a drug is adversely altered by the presence of\nanother disease condition.\n 12. "Drug-interactions" shall mean the occurrence where two or more\ndrugs taken by a recipient lead to clinically significant toxicity that\nis characteristic of one or any of the drugs present or that leads to\nthe interference with the effectiveness of one or any of the drugs.\n 13. "Therapeutic appropriateness" shall mean drug prescribing and\ndispensing based on rational drug therapy that is consistent with\ncriteria and standards of the compendia.\n 14. "Overutilization or underutilization" shall mean the use of a drug\nin such quantities where the desired therapeutic goal is not achieved.\n 15. "Appropriate and medically necessary" shall mean drug prescribing\nand dispensing and patient medication usage in conformity with the\ncriteria and standards developed under this chapter.\n 16. "Step therapy" shall mean the practice of beginning drug therapy\nfor a medical condition with the most medically appropriate and cost\neffective therapy and progressing to other drugs as medically necessary.\n