N.Y.
Social Services Law Section 369-AA
Definitions
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.
Source:
Section 369-AA — Definitions, https://www.nysenate.gov/legislation/laws/SOS/369-AA (updated Sep. 22, 2014; accessed Apr. 27, 2024).
