Title 12, HUMAN SERVICES

Sec. 13. As used in this chapter, "prospective DUR" means the part of the drug utilization review program that: (1) is to occur before the drug is dispensed; (2) is designed to screen for potential drug therapy problems based on explicit and predetermined criteria and standards t…

Sec. 14. As used in this chapter, "retrospective DUR" means the 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 that are developed on an ongoing…

Sec. 15. As used in this chapter, "standards" means the acceptable range of deviation from the criteria that reflects local medical practice and that is tested on the Medicaid recipient database. As added by P.L.75-1992, SEC.19.

Sec. 16. As used in this chapter, "SURS" refers to the surveillance utilization review system of the Medicaid program. As added by P.L.75-1992, SEC.19.

Sec. 17. As used in this chapter, "therapeutic appropriateness" means drug prescribing based on rational drug therapy that is consistent with the criteria and standards developed under this chapter. As added by P.L.75-1992, SEC.19.

Sec. 17.5. As used in this chapter, "therapeutic classification" or "therapeutic category" means a group of pharmacologic agents primarily characterized by a significant similarity of the biochemical or physiological mechanism by which these agents result in the intended clinical…

Sec. 18. As used in this chapter, "therapeutic duplication" means the prescribing and dispensing of: (1) the same drug; or (2) at least two (2) drugs from the same therapeutic class; where overlapping periods of drug administration are involved and where such prescribing or dispe…

Sec. 18.5. This chapter applies to any contractor or vendor of the state responsible for providing or managing any part of the Medicaid outpatient drug program. As added by P.L.76-1994, SEC.2.

Sec. 18.7. A formulary established by a managed care organization is subject to sections 46 and 47 of this chapter. As added by P.L.231-1999, SEC.2. Amended by P.L.152-2017, SEC.25.

Sec. 19. The drug utilization review board is established. As added by P.L.75-1992, SEC.19.

Sec. 2. As used in this chapter, "board" refers to the drug utilization review board created under this chapter. As added by P.L.75-1992, SEC.19.

Sec. 20. The board is composed of the following: (1) Four (4) individuals licensed and actively engaged in the practice of medicine or osteopathic medicine in Indiana under IC 25-22.5. (2) Four (4) individuals licensed under IC 25-26 and actively engaged in the practice of pharma…

Sec. 20.1. (a) Each board member and each therapeutics committee member shall fully disclose any potential conflicts of interest, financial or otherwise, relating to an issue that comes before the board or committee for recommendation or other action. (b) A board member or therap…

Sec. 20.5. (a) The therapeutics committee is established as a subcommittee of the board. (b) The chairperson of the board elected under section 25 of this chapter shall, with the approval of a majority of a quorum of the board, appoint the members of the therapeutics committee. (…

Sec. 21. (a) The members of the board shall be appointed by the governor and serve a term of three (3) years. (b) The governor shall fill a vacancy on the board by appointing a new member to serve the remainder of the unexpired term. (c) The governor may remove a member for cause…

Sec. 22. Board members must have expertise in one (1) or more of the following: (1) Clinically appropriate prescribing of outpatient drugs. (2) Clinically appropriate dispensing and monitoring of outpatient drugs. (3) Drug utilization review, evaluation, and intervention. (4) Med…

Sec. 23. In making the physician appointments, the governor shall provide for geographic balance. As added by P.L.75-1992, SEC.19.

Sec. 24. An individual appointed to the board may be reappointed upon the completion of the individual's term. As added by P.L.75-1992, SEC.19.

Sec. 25. (a) The board shall annually elect a chairman from the members of the board. (b) The chairman may be re-elected to serve consecutive terms as chairman. (c) A member of the board who is not a state employee is entitled to the minimum salary per diem as provided by IC 4-10…

Sec. 26. (a) The secretary shall provide additional staff to the board. (b) The secretary shall provide staff for the therapeutics committee. As added by P.L.75-1992, SEC.19. Amended by P.L.291-2001, SEC.162; P.L.107-2002, SEC.16.

Sec. 27. The board is responsible for the oversight of the retrospective and prospective DUR program. As added by P.L.75-1992, SEC.19.

Sec. 28. (a) The board has the following duties: (1) The implementation of a Medicaid retrospective and prospective DUR program as outlined in this chapter, including the approval of software programs to be used by the pharmacist for prospective DUR and recommendations concerning…

Sec. 28.5. The therapeutics committee established under section 20.5 of this chapter shall do the following: (1) Advise and make recommendations to the board in the board's development and maintenance of a preferred drug list under section 28 of this chapter. (2) Submit to the bo…

Sec. 28.7. (a) The board shall submit the initial approved preferred drug list to the office not later than August 1, 2002. (b) Except as permitted under subsection (g), the office may not further restrict the status of a drug in the Medicaid program or the children's health insu…

Sec. 29. (a) A quorum consists of six (6) voting members of the board. (b) DUR criteria and standards for appropriate prescribing may only be implemented with the approval of a majority of the quorum of the board. The majority vote must include at least three (3) of the four (4) …

Sec. 3. As used in this chapter, "compendia" means those resources widely accepted by the medical profession in the efficacious use of drugs, including the following sources: (1) The American Hospital Formulary Services Drug Information. (2) The U.S. Pharmacopeia-Drug Information…

Sec. 30. The criteria and standards developed under section 28(a)(3) of this chapter for appropriate prescribing that are implemented must reflect the local practices of physicians to monitor the following: (1) Therapeutic appropriateness. (2) Overutilization or underutilization.…

Sec. 31. (a) An intervention developed under section 28(a)(4) of this chapter that involves a physician must be approved by at least three (3) of the four (4) physician members of the board before implementation. (b) An intervention that involves a pharmacist must be approved by …

Sec. 32.1. The annual report under section 28 of this chapter shall include information on the following: (1) A description of the nature and scope of the prospective drug review program. (2) A description of how pharmacies performing prospective DUR without computers are expecte…

Sec. 34. (a) Information that identifies an individual collected under this chapter is confidential and may not be disclosed by the board. (b) The board may have access to identifying information for purposes of carrying out intervention activities. The identifying information ma…

Sec. 35. (a) Except as provided in IC 12-15-35.5-9, before the board develops a program to place a single source drug on prior approval, restrict the drug in its use, or establish a drug monitoring process or program to measure or restrict utilization of single source drugs other…

Sec. 36. The board may establish advisory committees to assist the board in carrying out the board's duties under this chapter. As added by P.L.75-1992, SEC.19.

Sec. 37. The board shall, in cooperation with the secretary, include in the Medicaid 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 …

Sec. 38. The retrospective and prospective DUR program shall be operated under the guidelines and procedures established by the board under section 29 of this chapter. As added by P.L.75-1992, SEC.19.

Sec. 39. Retrospective DUR must: (1) be based on the guidelines established by the board; and (2) use the mechanized drug claims processing and information retrieval system to analyze claims data to do the following: (A) Identify patterns of fraud, abuse, gross overuse, and inapp…

Sec. 4. As used in this chapter, "counseling" means the activities conducted by a pharmacist to inform Medicaid recipients about the proper use of drugs as required by the board under this chapter. As added by P.L.75-1992, SEC.19.

Sec. 4.5. As used in this chapter, "covered outpatient drug" has the meaning set forth in 42 U.S.C. 1396r-8(k)(2). As added by P.L.107-2002, SEC.12.

Sec. 40. Prospective DUR must be based on the guidelines established by the board and must 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 fr…

Sec. 41. The activities of the board in carrying out this chapter are covered under IC 34-30-15. As added by P.L.75-1992, SEC.19. Amended by P.L.1-1998, SEC.103.

Sec. 42. (a) The board may meet in an executive session for purposes of reviewing DUR data or to conduct or to discuss activity as provided for in IC 5-14-1.5-6.1. (b) The board shall also conduct regular public meetings to gather input from the public on the operation of the DUR…

Sec. 43. Confidential data or information obtained by pharmacists as part of prospective DUR are confidential but may be released to prescribers or others according to procedures established by the board. As added by P.L.75-1992, SEC.19.

Sec. 43.5. (a) The board, the therapeutics committee, or the office may not release proprietary or confidential information obtained as part of the development, implementation, or maintenance of a preferred drug list under this chapter. (b) Information described in subsection (a)…

Sec. 44. A person who does not comply with the confidentiality provisions under section 34 of this chapter commits a Class A misdemeanor. As added by P.L.75-1992, SEC.19. Amended by P.L.1-1993, SEC.133.

Sec. 45. (a) The chairman of the board, subject to the approval of the board members, may appoint an advisory committee to make recommendations to the board on the development of a Medicaid outpatient drug formulary. (b) If the office decides to establish a Medicaid outpatient dr…

Sec. 46. (a) This section applies to a managed care organization that enters into an initial contract with the office to be a managed care organization after May 13, 1999. (b) Before a managed care organization described in subsection (a) implements a formulary, the managed care …

Sec. 47. (a) This section applies to the following changes to a formulary used by a managed care organization for Medicaid recipients: (1) Removing one (1) or more drugs from the formulary. (2) Placing new restrictions on one (1) or more drugs on the formulary. (b) Before a manag…