NY Soc Serv L § 369-AA (2021)
2021 New York Laws SOS - Social Services Article 5 - Assistance and Care Title 11-C - Medicaid Drug Utilization Review 369-AA - Definitions.

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