2023 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.