2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11-C - Medicaid Drug Utilization Review › 369-BB - Drug Utilization Review Board.

§  369-bb.  Drug  utilization review board.   1. A twenty-three-member
drug utilization review board is hereby created in the  department.  The
board is responsible for the establishment and implementation of medical
standards  and  criteria  for  the  retrospective  and  prospective  DUR
program.
2. The members of the DUR board shall be appointed by the commissioner
and shall serve a three-year term. Members may be reappointed  upon  the
completion  of  other  terms.  The  membership shall be comprised of the
following:
(a) Six persons licensed and  actively  engaged  in  the  practice  of
medicine  in  the  state,  with expertise in the areas of mental health,
HIV/AIDS, geriatrics, pediatrics or internal medicine  and  who  may  be
selected  based  on input from professional associations and/or advocacy
groups in New York state.
(b) Six persons licensed and actively practicing in  pharmacy  in  the
state  who may be selected based on input from professional associations
and/or advocacy groups in New York state.
(c) Two persons with expertise in  drug  utilization  review  who  are
health care professionals licensed under Title VIII of the education law
at least one of whom is a pharmacologist.
(d)  Three  persons  that are consumers or consumer representatives of
organizations with a regional or statewide  constituency  and  who  have
been  involved  in  activities related to health care consumer advocacy,
including issues affecting Medicaid or EPIC recipients.
(e)  One  person  licensed  and  actively  practicing   as   a   nurse
practitioner or midwife.
(f) Two persons who are health care economists.
(g) One person who is an actuary.
(h) One person representing the department of financial services.
(i)  The  commissioner shall designate a person from the department to
serve as chairperson of the board.
3. The appointed members to the board, or its  agents  shall  have  no
sanctions against them by medicare or medicaid.
4.  The appointments to this board shall be made so that the length of
the terms are staggered. In making the  appointments,  the  commissioner
shall consider geographic balance in the representation on the board.
5.  (a)  The  functions,  powers and duties of the former pharmacy and
therapeutics committee as established in article  two-A  of  the  public
health  law  shall  now be considered a function of the drug utilization
review board, including but not limited to:
(i) conducting an executive session for the purpose of  receiving  and
evaluating  drug pricing information related to supplemental rebates, or
receiving and evaluating trade secrets, or other information  which,  if
disclosed, would cause substantial injury to the competitive position of
the manufacturer; and
(ii)  evaluating  and providing recommendations to the commissioner of
health on other issues relating to pharmacy services under  Medicaid  or
EPIC,  including,  but not limited to: therapeutic comparisons; enhanced
use  of  generic  drug  products;  enhanced   targeting   of   physician
prescribing patterns; and
(iii)  collaborating  with  managed care organizations to address drug
utilization concerns and to implement consistent  management  strategies
across the fee-for-service and managed care pharmacy benefits.
(b)  Any  business  or  other  matter  undertaken  or commenced by the
pharmacy and therapeutics committee pertaining to or connected with  the
functions,  powers,  obligations  and  duties are hereby transferred and
assigned to the  drug  utilization  review  board  and  pending  on  the
effective  date  of  this subdivision, may be conducted and completed by

the drug utilization review board in the same manner and under the  same
terms  and  conditions  and  with  the  same  effect as if conducted and
completed by the pharmacy and therapeutics committee. All books, papers,
and  property  of the pharmacy and therapeutics committee shall continue
to be maintained by the drug utilization review board.
(c)  All  rules,  regulations,  acts,  orders,   determinations,   and
decisions  of  the pharmacy and therapeutics committee pertaining to the
functions and powers herein transferred and assigned, in  force  at  the
time  of  such transfer and assumption, shall continue in full force and
effect as rules, regulations, acts, orders, determinations and decisions
of the drug utilization review board until duly modified or abrogated by
the commissioner of health.
6. Members of the DUR utilization review board and all  its  employees
and  agents  shall be deemed to be an "employee" for purposes of section
seventeen of the public officers law.
7. The department shall provide  administrative  support  to  the  DUR
board.
8. The duties of the DUR board are as follows:
(a)  The development and application of the predetermined criteria and
standards to be used in retrospective and prospective  DUR  that  ensure
that  such  criteria  and  standards are based on the compendia and that
they are developed with professional input in a consensus  fashion  with
provisions  for  timely revisions and assessments as necessary. Further,
that the DUR  standards  shall  reflect  the  appropriate  practices  of
physicians in order to monitor:
(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.
(b)   The  development,  selection,  application,  and  assessment  of
interventions or remedial strategies for  physicians,  pharmacists,  and
recipients  that  are  educational and not punitive in nature to improve
the quality of care including:
(i) Information disseminated to physicians and pharmacists  to  ensure
that  physicians  and  pharmacists  are  aware of the board's duties and
powers;
(ii) Written, oral, or electronic  reminders  of  patient-specific  or
drug-specific   information  that  are  designed  to  ensure  recipient,
physician, and pharmacist confidentiality, and suggested changes in  the
prescribing  or  dispensing practices designed to improve the quality of
care;
(iii) Use of face-to-face discussions between experts in drug  therapy
and  the  prescriber or pharmacist who has been targeted for educational
intervention;
(iv) Intensified reviews or  monitoring  of  selected  prescribers  or
pharmacists;
(v) The creation of an educational program using data provided through
DUR  to  provide for active and ongoing educational outreach programs to
improve  prescribing  and  dispensing  practices  as  provided  in  this
subdivision.  (This  may be done directly or through contract with other
entities);
(vi) The timely  evaluation  of  interventions  to  determine  if  the
interventions have improved the quality of care; and
(vii)  The  review  of  case  profiles  prior  to the conducting of an
intervention.
(c) The publication of an annual report which shall be subject to  the
department's  comment prior to its issuance to the federal department of
health and human services by December first of  each  year.  The  annual
report  also  shall  be  submitted  to  the governor and the legislature
before  December  first  of  each  year.  The  report  shall include the
following information:
(i) A description of the activities of the board, including the nature
and scope of the prospective and retrospective drug use review programs;
(ii) A summary of the interventions used;
(iii) An assessment of the impact of these  educational  interventions
in quality of care;
(iv)  An  estimate  of  the cost savings generated as a result of such
program; and
(v) Recommendations for program improvement.
(d) The development of a working agreement  for  the  DUR  board  with
related  boards or agencies, including, but not limited to: the board of
pharmacy, the board of medicine,  the  SURS  staff,  and  staff  of  the
department  of  health  and  the  office  of  mental health, in order to
clarify the areas of  responsibility  for  each  where  such  areas  may
overlap.
(e)  The  establishment  of  a process where physicians or pharmacists
will have the opportunity to submit responses  to  the  DUR  educational
letters.
(f)  The  publication  and dissemination of educational information to
physicians and pharmacists on the DUR  board  and  the  DUR  program  to
include information on:
(i)  Identifying  and  reducing  the  frequency  of patterns of fraud,
abuse, gross overuse, or inappropriate  or  medically  unnecessary  care
among physicians, pharmacists, and recipients;
(ii) Potential or actual severe/adverse reactions to drugs;
(iii) Therapeutic appropriateness;
(iv) Overutilization or underutilization;
(v) Appropriate use of generics;
(vi) Therapeutic duplication;
(vii) Drug-disease contraindications;
(viii) Drug-drug interactions;
(ix) Incorrect drug dosage/duration of drug treatments;
(x) Drug allergy interactions; and
(xi) Clinical abuse/misuse.
(g) The evaluation of specific drugs submitted to the board for review
pursuant to section two hundred eighty of the public health law, and the
formulation  of  recommended  target supplemental rebates, in accordance
with the standards established in such section.
(h) The adoption and implementation of procedures designed  to  ensure
the  confidentiality  of  any  information collected, stored, retrieved,
assessed  or  analyzed  by  the  DUR  board,  staff  to  the  board,  or
contractors  to  the DUR program, that identifies individual physicians,
pharmacists, or recipients. The board may  have  access  to  identifying
information  for  purposes  of carrying out intervention activities, but
such identifying information may not be released to anyone other than  a
member of the DUR board or the department and its agents.
(i)  The  improper  release of identifying information in violation of
this article may subject that person to criminal or civil penalties.
(j) The board may release cumulative non-identifying  information  for
purposes of legitimate research.
9. The relationship of the DUR board to the department is as follows:
(a) The department shall monitor the DUR board's compliance to federal
and state statute and regulation.
(b) The DUR board shall serve at the discretion of the commissioner.
(c) The department shall have authority on all fiscal matters relating
to the DUR program.
(d)  The department shall have authority on all administrative matters
relating to the administration of the medical assistance program  within
the DUR program.
(e)  The  DUR  board shall have responsibility for all medical matters
relating to the DUR program.
(f)  The  DUR  board  may  utilize  medical  consultants  and   review
committees as necessary, subject to department approval.