2023 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.