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

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