N.Y. Social Services Law § 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.