N.Y. Social Services Law § 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.