§ 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.