CurrentExecutive Office of Health and Human ServicesPolicy N/A

Drug Utilization Review (DUR) Board — Pharmacy Coverage Criteria and Program Actions

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Summarizes DUR Board discussions, surveillance findings, and recommended program actions related to controlled substances, antipsychotics in children, hepatitis C agents, PDL changes, and other pharmacy utilization issues affecting Rhode Island Medicaid beneficiaries and prescribers.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDrug Utilization Review (DUR) Board — Pharmacy Coverage Criteria and Program Actions

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateN/A

Next Review DateJun 3, 2014

Key ActionVerify patients meeting automatic lock-in criteria for hospice status and restrict eligible patients to a single pharmacy per program procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

92enrolled in lock-in

13children on antipsychotics (Q4 2013)

43patients >100 mg reviewed

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

Drug Utilization Review (DUR) Board — Pharmacy Coverage Criteria and Program Actions

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Sign up for all Executive Office of Health and Human Services policy alerts

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Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDrug Utilization Review (DUR) Board — Pharmacy Coverage Criteria and Program Actions

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateN/A

Next Review DateJun 3, 2014

Key ActionVerify patients meeting automatic lock-in criteria for hospice status and restrict eligible patients to a single pharmacy per program procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

92enrolled in lock-in

13children on antipsychotics (Q4 2013)

43patients >100 mg reviewed

patients >100 mg with cancer

Top 10non-responder prescribers

Coverage Criteria and DUR Recommendations

Automatic Lock-in

Automatic lock-in recommendation

Automatic lock-in when ALL met: Patient has 6 or more claims for controlled substances from 3 or more pharmacies and 2 or more prescribers in the most recent 30 days6+ claims; >=3 pharmacies; >=2 prescribers in 30 days

Patients meeting criteria will be verified for hospice status before lock-in

Opioid Safety Interventions

DUR intervention criteria for opioid safety

Triggers for DUR letters: Patients receiving opioids at >100 mg morphine equivalents>100 mg morphine equivalents

HID reviewed diagnosis data for patients >100 mg morphine equivalents to inform interventions

Triggers for DUR letters: Patients receiving concurrent therapy with opioids and benzodiazepinesconcurrent opioid + benzodiazepine

Board recommended adding PDMP language to DUR intervention letters and raising awareness of naloxone availability

Antipsychotics in Children

Pediatric antipsychotic monitoring

Underage antipsychotic use: Children identified who are under the FDA‑approved age for the antipsychotic; prescribers to receive intervention letters and a summary of FDA‑approved indications and agesidentified cases (13 in Q4 2013)

HID to review prescriber responses regarding awareness and monitoring

Concurrent stimulant + antipsychotic review: Children with concurrent claims for stimulants and antipsychotics to have prescribers contacted to determine clinical rationalecases identified in DUR review

HID to attempt to capture prescriber rationale via response form or direct contact

Hepatitis C Agents Prior Authorization

Hepatitis C therapy management

Prior authorization development: A task force will develop prior authorization criteria for new hepatitis C agents with anticipated completion by July 1, 2014; MCOs to align with fee‑for‑service criteria and continue therapy for patients who meet criteria upon MCO enrollmenttask force timeline to July 1, 2014

Patients should not be initiated on therapy if likely to be non‑adherent to a full course

PDL Changes

Formulary and PDL changes

Preferred drug list actions: Victoza (liraglutide) designated non‑preferred — current patients may continue without prior authorizationPDL designation changes

Significant PDL changes may be communicated in the Provider Bulletin

Preferred drug list actions: Novolin insulin designated non‑preferred; patients will be transitioned to Humulin unless prior authorization is obtained for NovolinPDL designation changes

HID to alert prescribers and implement transition or prior authorization process

Patients identified for the automatic lock-in program will be checked for hospice status before any restriction is applied. The DUR Board directed that any patient who meets the proposed automatic lock-in criteria — defined as 6 or more claims for controlled substances from 3 or more pharmacies and 2 or more prescribers in the most recent 30 days — be verified to determine if they are a hospice patient, since hospice beneficiaries typically have a single prescriber and would be handled differently.

Key Thresholds and Operational Definitions

inv-07: High-dose opioid threshold — > 100 mg morphine equivalents

High-dose opioid threshold> 100 mg morphine equivalents

Used for DUR intervention lettersPatients receiving opioids at a dose greater than 100 mg morphine equivalents trigger prescriber outreach

Diagnosis reviewHID reviewed diagnoses for patients meeting this threshold (43 patients; 6 with cancer)

inv-08: Lock-in automatic criteria — 6+ controlled substance claims from >=3 pharmacies and >=2 prescribers in 30 days

Lock-in automatic criteria6+ controlled substance claims from >=3 pharmacies and >=2 prescribers in the most recent 30 days

Verification stepPatients meeting criteria will be verified for hospice status prior to lock-in

Actions, Prior Authorizations, and Formulary Notices for Providers

Prior Authorization

Prior authorization expected for hepatitis C agents; PA required to continue Novolin instead of transition to Humulin

A prior authorization (PA) framework for new hepatitis C agents is being developed by a task force with completion expected by July 1, 2014; providers should expect MCOs and fee-for-service to implement aligned PA criteria and ensure patients meet fee-for-service criteria prior to initiation. For Novolin-to-Humulin transitions, prescribers must obtain prior authorization if they wish a patient to remain on Novolin when clinical indications warrant continuation instead of transitioning to Humulin.

Task force to develop PA criteria for new hepatitis C agents; target completion July 1, 2014.
MCOs will continue therapy for patients who met fee-for-service criteria at time of MCO enrollment without requiring additional PA.
Prescribers must obtain PA to continue Novolin when clinical justification exists; otherwise patients will be transitioned to Humulin.

Step Therapy

Victoza designated non-preferred — existing patients may continue without PA

Community and Public Health Pharmacy Actions

Note

Naloxone availability on EMT/police vehicles and at Walgreens without a prescription

Naloxone is available on all EMT and police vehicles, and an agreement with Walgreens allows any individual to obtain naloxone at Walgreens pharmacies in Rhode Island without a prescription; prescribers of top opioid prescribers and those treating lock-in patients should be informed so they can advise patients and caregivers.

Naloxone is available in injectable form and as a nasal spray; an auto-injector device was recently approved by the FDA.
Recommend notifying high-volume opioid prescribers and prescribers of lock-in patients about naloxone availability at Walgreens.

Step Therapy and PDL Management

Drug	PDL status / Step therapy action	Notes
{"text":"Victoza (liraglutide)","status":""}\|{"text":"non-preferred","status":""}\|{"text":"Prescribers to receive intervention letters; current patients may continue therapy without prior authorization; new starts will be managed per PDL/step processes.","status":""}

Background and Board Review Summary

The Board reviewed patterns of opioid overuse and discussed the role of pharmacy lock-in programs as a tool to limit fragmented controlled-substance access. Members considered models used by other state Medicaid programs — including programs that restrict patients to a single pharmacy by committee review and programs that apply automatic criteria — and favored adopting similar automatic restriction criteria. The discussion also acknowledged potential unintended consequences of more restrictive policies (for example, reduced willingness of emergency prescribers to treat pain and possible diversion) and noted that lock-in can support the pharmacist’s role as a member of the care team. The Board reviewed alternative approaches such as limiting long-term access to short-acting opioids while emphasizing surveillance and targeted interventions for high-risk prescribing patterns.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDrug Utilization Review (DUR) Board — Pharmacy Coverage Criteria and Program Actions

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateN/A

Next Review DateJun 3, 2014

Key ActionVerify patients meeting automatic lock-in criteria for hospice status and restrict eligible patients to a single pharmacy per program procedures.

SourceLink

On This Page

PurposeRecommend automatic restriction to a single pharmacy to limit multiple-source opioid access

inv-09: Opioid overuse monitoring — short-acting opioid > 90 days; total day supply > 120 days in most recent 90 days

Short-acting opioid durationUse of short-acting opioids for more than 90 days triggers monitoring

Total day supply thresholdTotal day supply > 120 days of any controlled substance in the most recent 90 days

Concurrent therapy flagConcurrent opioid and benzodiazepine therapy is an additional trigger for DUR letters

inv-16: Automatic lock-in criteria (definition) — restated operational definition for lock-in triggering

Operational definitionAutomatic lock-in triggers when ALL are met: 6 or more claims for controlled substances from 3 or more pharmacies and 2 or more prescribers in the most recent 30 days

Exclusion checkPatients meeting criteria will be verified to determine hospice status before applying lock-in

Program intentRestrict patient to a single pharmacy to reduce multi-source opioid access and allow pharmacist monitoring

inv-17: High-dose opioid (definition) — definition used for DUR intervention letters

Definition used for DUR lettersHigh-dose opioid defined as opioid dosing greater than 100 mg morphine equivalents

ApplicationTriggers prescriber outreach and diagnostic review for patients above this threshold

ContextHID reviewed diagnostic profiles for patients meeting this definition to inform interventions

Victoza (liraglutide) will be designated non-preferred on the PDL; current patients may continue therapy without prior authorization, while new starts may be subject to PDL/step-management processes.

Prescribers of existing Victoza patients do not need to submit PA for continuation.
New initiations may be managed according to the PDL (step therapy/non-preferred handling).

Documentation Required

HID to track and document prescriber responses to DUR letters

HID will review and document prescriber responses to DUR intervention letters, including whether prescribers acknowledge underage antipsychotic use, monitoring plans, or other response content; HID will report back on responses (including non-responders) at subsequent meetings.

HID to record prescriber acknowledgements of awareness and monitoring for underage antipsychotic use.
HID to compile and report prescriber response data, including top non-responders, and to draft follow-up letters to persistent non-responders.

Denial Risk

Automatic lock-in trigger for patients meeting multi-prescriber/multi-pharmacy threshold

Patients who meet automatic lock-in criteria — defined as receiving 6 or more controlled‑substance claims from three or more pharmacies and two or more prescribers in the most recent 30 days — may be restricted to a single pharmacy; HID will verify hospice status before imposing lock-in.

Criterion: 6+ controlled substance claims from >=3 pharmacies and >=2 prescribers within 30 days.
HID will verify whether flagged patients are hospice patients (who would normally be excluded) before lock-in is applied.

Billing Rule

Novolin becomes non-preferred — transition to Humulin or PA required

Novolin insulin will become non-preferred on the PDL and patients will be transitioned to Humulin unless a prior authorization is obtained for clinical reasons; providers should notify patients and request PA when continuation of Novolin is clinically indicated.

Novolin designated non-preferred; routine coverage expected to shift toward Humulin.
Prescribers must obtain prior authorization to keep a patient on Novolin for clinical indication rather than transition to Humulin.