§ 369-CC — Retrospective and prospective drug utilization review

§ 369-cc. Retrospective and prospective drug utilization review. The\ndepartment, in cooperation with the DUR board, shall include in its\nstate plan the creation and implementation of a retrospective and\nprospective DUR program for medicaid outpatient drugs to ensure that the\nprescriptions are appropriate, medically necessary, and not likely to\nresult in adverse medical outcomes.\n 1. The retrospective and prospective DUR program shall be operated\nunder the guidelines and procedures established by the DUR board.\n 2. The retrospective DUR program shall be based on the guidelines\nestablished by the DUR board and shall use the mechanized drug claims\nprocessing and information retrieval system to analyze claims data to:\n (a) Identify patterns of gross overuse, and inappropriate or medically\nunnecessary care.\n (b) Assess data on drug use against explicit predetermined standards\nthat are based on the compendia and other sources to monitor the\nfollowing:\n (i) Therapeutic appropriateness;\n (ii) Overutilization or underutilization;\n (iii) Therapeutic duplication;\n (iv) Drug-disease contraindications;\n (v) Drug-drug interactions;\n (vi) Incorrect drug dosage or duration of drug treatment; and\n (vii) Clinical abuse/misuse.\n 3. The prospective DUR program shall be based on the guidelines\nestablished by the DUR board not in conflict with education or social\nservices laws and shall provide that prior to the prescription being\nfilled or delivered, a review will be conducted by the pharmacist at the\npoint of sale to screen for potential drug therapy problems resulting\nfrom:\n (a) Therapeutic duplication;\n (b) Drug-drug interactions;\n (c) Incorrect dosage/duration of treatment;\n (d) Drug-allergy interactions;\n (e) Clinical abuse/misuse.\nIn conducting the prospective DUR, the pharmacist may not alter the\nprescribed outpatient drug therapy without the consent of the prescriber\nwho prescribed that therapy.\n 4. (a) The commissioner, through the prospective DUR program, may\nrequire step therapy when there is more than one drug appropriate to\ntreat a medical condition. The purpose of step therapy is to encourage\nthe use of medically appropriate, cost effective drugs when clinically\nindicated and to limit use of alternative drug therapies unless certain\nclinical requirements are met. The DUR board shall recommend guidelines\nfor specific diagnoses and therapy regimens within which practitioners\nmay prescribe drugs without the requirement for prior authorization of\nthose drugs. In establishing these guidelines, the board shall consider\nclinical effectiveness, safety, and cost effectiveness. Prior\nauthorization under this paragraph shall be obtained under section two\nhundred seventy-three of the public health law.\n (b) The commissioner, through the prospective DUR program, may from\ntime to time limit the quantity, frequency, and duration of drug\ntherapy, using guidelines developed by the DUR board. The DUR board\nshall develop clinical prescribing guidelines relating to quantity,\nfrequency, and duration of drug therapy for the commissioner's use under\nthis paragraph. In establishing these guidelines, the board shall\nconsider clinical effectiveness, safety, and cost effectiveness. Prior\nauthorization under this paragraph shall be obtained under section two\nhundred seventy-three of the public health law. Exceptions to any prior\nauthorization imposed as a result of these guidelines shall include, but\nneed not be limited to, provision for emergency circumstances where a\nmedical condition requires alleviation of severe pain or which threatens\nto cause disability or to take a life if not promptly treated.\n