Section 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.