ยง 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.