The board shall:
(1)develop rules necessary to carry out its responsibilities as defined in this part;
(2)oversee the implementation of a Medicaid retrospective and prospective DUR program in accordance with this part, including responsibility for approving provisions of contractual agreements between the Medicaid program and any other entity that will process and review Medicaid drug claims and profiles for the DUR program in accordance with this part;
(3)develop and apply predetermined criteria and standards to be used in retrospective and prospective DUR, ensuring that the criteria and standards are based on the compendia, and that they are developed with professional input, in a consensus fashion, with provisions for timely revision and assessment as necessary. The DUR standards de
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The board shall:
(1) develop rules necessary to carry out its responsibilities as defined in this part;
(2) oversee the implementation of a Medicaid retrospective and prospective DUR program in accordance with this part, including responsibility for approving provisions of contractual agreements between the Medicaid program and any other entity that will process and review Medicaid drug claims and profiles for the DUR program in accordance with this part;
(3) develop and apply predetermined criteria and standards to be used in retrospective and prospective DUR, ensuring that the criteria and standards are based on the compendia, and that they are developed with professional input, in a consensus fashion, with provisions for timely revision and assessment as necessary. The DUR standards developed by the board shall reflect the local practices of physicians in order to monitor:
(3)(a) therapeutic appropriateness;
(3)(b) overutilization or underutilization;
(3)(c) therapeutic duplication;
(3)(d) drug-disease contraindications;
(3)(e) drug-drug interactions;
(3)(f) incorrect drug dosage or duration of drug treatment; and
(3)(g) clinical abuse and misuse;
(4) develop, select, apply, and assess interventions and remedial strategies for physicians, pharmacists, and recipients that are educational and not punitive in nature, in order to improve the quality of care;
(5) disseminate information to physicians and pharmacists to ensure that they are aware of the board's duties and powers;
(6) provide written, oral, or electronic reminders of patient-specific or drug-specific information, designed to ensure recipient, physician, and pharmacist confidentiality, and suggest changes in prescribing or dispensing practices designed to improve the quality of care;
(7) utilize face-to-face discussions between experts in drug therapy and the prescriber or pharmacist who has been targeted for educational intervention;
(8) conduct intensified reviews or monitoring of selected prescribers or pharmacists;
(9) create an educational program using data provided through DUR to provide active and ongoing educational outreach programs to improve prescribing and dispensing practices, either directly or by contract with other governmental or private entities;
(10) provide a timely evaluation of intervention to determine if those interventions have improved the quality of care;
(11) publish the annual Drug Utilization Review report required under 42 C.F.R. Sec. 712;
(12) develop a working agreement with related boards or agencies, including the State Board of Pharmacy, Medical Licensing Board, and SURS staff within the division, in order to clarify areas of responsibility for each, where those areas may overlap;
(13) establish a grievance process for physicians and pharmacists under this part, in accordance with Title 63G, Chapter 4, Administrative Procedures Act;
(14) publish and disseminate educational information to physicians and pharmacists concerning the board and the DUR program, including information regarding:
(14)(a) identification and reduction of the frequency of patterns of fraud, abuse, gross overuse, inappropriate, or medically unnecessary care among physicians, pharmacists, and recipients;
(14)(b) potential or actual severe or adverse reactions to drugs;
(14)(c) therapeutic appropriateness;
(14)(d) overutilization or underutilization;
(14)(e) appropriate use of generics;
(14)(f) therapeutic duplication;
(14)(g) drug-disease contraindications;
(14)(h) drug-drug interactions;
(14)(i) incorrect drug dosage and duration of drug treatment;
(14)(j) drug allergy interactions; and
(14)(k) clinical abuse and misuse;
(15) develop and publish, with the input of the State Board of Pharmacy, guidelines and standards to be used by pharmacists in counseling Medicaid recipients in accordance with this part. The guidelines shall ensure that the recipient may refuse counseling and that the refusal is to be documented by the pharmacist. Items to be discussed as part of that counseling include:
(15)(a) the name and description of the medication;
(15)(b) administration, form, and duration of therapy;
(15)(c) special directions and precautions for use;
(15)(d) common severe side effects or interactions, and therapeutic interactions, and how to avoid those occurrences;
(15)(e) techniques for self-monitoring drug therapy;
(15)(f) proper storage;
(15)(g) prescription refill information; and
(15)(h) action to be taken in the event of a missed dose; and
(16) establish procedures in cooperation with the State Board of Pharmacy for pharmacists to record information to be collected under this part. The recorded information shall include:
(16)(a) the name, address, age, and gender of the recipient;
(16)(b) individual history of the recipient where significant, including disease state, known allergies and drug reactions, and a comprehensive list of medications and relevant devices;
(16)(c) the pharmacist's comments on the individual's drug therapy;
(16)(d) name of prescriber; and
(16)(e) name of drug, dose, duration of therapy, and directions for use.