Section He-C 5010.07 - Functions and Responsibilities of the DUR Board(a) The DUR board shall hold meetings no less than semi-annually.(b) Based on 42 USC 1396r-8(g) (1) (A) and (B) , the DUR board shall make recommendations to the commissioner regarding policy, procedures, and standards for the implementation of the medicaid pharmacy benefit, the primary focus of which shall be the education of providers and medicaid recipients to maximize the quality of care provided.(c) The DUR board shall advise the commissioner regarding: (1) The clinical operation of the pharmacy benefit management program;(2) Which medications are subject to prior authorization, pursuant to He-C 5010.08(d) ; and(3) The criteria required for prior authorization to be granted, pursuant to He-C 5010.08(d) .(d) The DUR board shall develop a retrospective DUR program in accordance with the following: (1) The DUR board shall recommend to the commissioner the standards for the mechanized drug claims processing and information retrieval system;(2) The DUR board shall recommend to the commissioner parameters for the PBM's performance of ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among prescribers, pharmacists, and recipients; and(3) The DUR board shall review recommendations of the PBM's pharmacist and physician, which shall be based upon evidence-based and peer-reviewed medical literature or at least one of the following compendia: a. American Hospital Formulary Service Drug Information;b. United States Pharmacopoeia-Drug Information; orc. American Medical Association Drug Evaluations. (e) In accordance with 42 USC 1396r-8(g) (3) (C) , the DUR board shall recommend ongoing educational interventions for: (1) Prescribers and pharmacists, targeted toward over use, under use, or misuse of pharmacy services or benefits; and(2) Individuals identified in the course of retrospective drug use reviews performed under (d) above.(f) Recommendations made pursuant to (e) above shall include: (1) Information to prescribers and pharmacists concerning the DUR board's duties, functions, and responsibilities;(2) Written, oral, or electronic reminders concerning patient-specific or drug-specific information, or both, with suggested changes in prescribing or dispensing practices, communicated in a manner designated to ensure the privacy of patient-related information;(3) The use of face-to-face discussions between health care professionals who are experts in rational drug therapy and prescribers and pharmacists who have been targeted for educational intervention; and(4) The intensified review or monitoring of prescribers or pharmacists who have been targeted for review under this section.(g) The DUR board shall re-evaluate interventions as described in (f) above, after a period of time which the DUR board has determined is sufficient, based on the specific circumstances of the prescribing practice under review, to determine if the interventions improved the quality of drug therapy, to evaluate the success of the interventions, and to recommend modifications as necessary.(h) The DUR board shall prepare an annual report to be provided to the commissioner.(i) The annual report in (h) above shall include: (1) A description of the activities of the DUR board, including the nature and scope of the prospective and retrospective DUR programs;(2) A summary of the interventions used;(3) An assessment of the impact of these interventions on quality of care; and(4) An estimate of the cost savings generated as a result of such programs.(j) The DUR board shall advise the commissioner on the criteria for the pharmacy lock-in program defined in He-W 570.01 and described more particularly at He-W 570.07.(k) Other reports and data shall be provided by the DUR board to the commissioner at such time and in such format as he or she requests.N.H. Admin. Code § He-C 5010.07
#5529, eff 12-16-92; amd by #5608, eff 4-6-93; ss by #6907, eff 12-9-98; ss by #8743, eff 10-24-06; ss by #9587, eff 11-4-09 (from He-C 5010.08 )
Amended by Volume XXXVIII Number 06, Filed February 8, 2018, Proposed by #12460, Effective 1/13/2018, Expires 1/13/2028.