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    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsEOHHS DUR tracking update — Coverage & Prior Auth …
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    CurrentExecutive Office of Health and Human ServicesPolicy N/A

    DUR Board follow-up: monitored utilization and tracking (coverage criteria)

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    Summarizes Drug Utilization Review Board discussions, follow-up items, utilization metrics, and tracking requests for Rhode Island Medicaid (FFS) across multiple drug categories; affects EOHHS program staff, DUR board members, pharmacy benefit managers (Gainwell, Acentra), and Medicaid providers involved in prescribing/monitoring these therapies.

    Policy Summary
    PayerExecutive Office of Health and Human Services
    PolicyDUR Board follow-up: monitored utilization and tracking (coverage criteria)
    Policy CodePolicy N/A
    Change TypeInformational / tracking update
    Effective DateN/A
    Next Review DateN/A
    Key ActionProviders must document prior oral therapy when requesting review of transitions to long-acting injectable antipsychotics (claims review requested).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    228opioid-related fatalities in RI (2024)
    125GLP/GIP users for T2DM (Q2 2025)
    53GLP/GIP users for weight loss (Q2 2025)
    13

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    chronic opioid therapy without naloxone (Q2 2025)
    6recipients receiving tramadol (Q2 2025)

    Coverage and Monitoring Criteria

    Monitored utilization criteria (DUR follow-up)

    Follow-up monitoring and intervention criteria discussed by the DUR Board (covered when meeting criteria triggers case creation and outreach):

    Concurrent benzodiazepine and opioid use: Recipients identified with concurrent benzodiazepine and opioid prescriptions generated intervention letters; 9 recipients identified and 9 cases created during 2nd quarter 2025 (0.005% of FFS).concurrent use

    Board requested further follow-up regarding overdose fatalities involving benzodiazepines and to continue tracking; Acentra to follow up in December.

    High-dose opioid use: Recipients receiving > 90 MME daily generated cases; 1 recipient identified during 2nd quarter 2025 (0.002% of FFS).> 90 MME daily

    Continue tracking for FFS; benchmarking provided and Acentra to follow up in December.

    Stimulant exceeding max dose: Recipients exceeding stimulant maximum-dose criteria generated cases; 6 recipients identified during 2nd quarter 2025.per stimulant-specific max dose criteria

    Include age >= 40 cardiovascular risk check; continue tracking.

    Chronic opioid therapy without naloxone: Recipients on chronic opioid therapy without naloxone generated cases; 13 recipients and 13 cases were created during 2nd quarter 2025 (one response received).chronic opioid therapy without naloxone

    Board elected to retain current mailer response options and continue tracking; consider drill-down where concurrent CNS depressants are present.

    GLP-1/GIP use in women of childbearing potential: Recipients of GLP-1/GIP agents flagged for pregnancy-related safety concerns; 10 unique recipients and 10 cases during 2nd quarter 2025.women of childbearing potential using GLP-1/GIP

    Acentra uses documented pregnancy diagnosis only (not inferred by prenatal vitamins); Board to research evidence base and continue tracking.

    Atypical antipsychotic use under indicated age: Pediatric recipients receiving atypical antipsychotics under the indicated age generated cases; 6 recipients identified during 2nd quarter 2025 (0.05% pediatric FFS).age-based indication criteria

    Case example: Abilify Maintena ER recipient transitioned from oral aripiprazole (2017) to LAI (2024); Board recommended further provider outreach and continued tracking.

    The Board reviewed Invega Hafyera utilization and found a single FFS recipient who began therapy in November 2024 while transitioning from Invega Trinza. Follow-up showed additional Invega Trinza claims in November 2024, February 2025, and May 2025, and no further Invega Hafyera prescriptions. NHP reported a few patients on Invega Hafyera, but overall the Board concluded that use within the FFS Medicaid population did not represent a concern. As a result, the Board requested that active tracking of Invega Hafyera utilization for FFS Medicaid be discontinued.

    The Board reviewed a pediatric case involving Abilify Maintena (aripiprazole long-acting injectable). Claims review showed the recipient was started on oral daily aripiprazole in 2017 and transitioned to the LAI formulation in 2024. The Board characterized this use as off-label, investigational, and questionable for the pediatric recipient and recommended sending the case details to EOHHS for further outreach to the prescribing provider. Gainwell and Acentra were asked to continue review and to follow up at their monthly status meetings; the Board also requested continued tracking of atypical antipsychotic use under the indicated age.

    Key Coding Thresholds

    inv-04: >90 MME daily — coding threshold/value
    > 90 MME dailyThreshold defined as recipients receiving more than 90 Morphine Milligram Equivalent (MME) per day
    Monitoring result (2nd quarter 2025)1 recipient identified (0.002% of FFS population)
    BenchmarkApproximately 0.1% of the comparison state's population exceeded 90 MME daily
    inv-05: Tramadol max dose — 300 mg/day
    Tramadol maximum daily dose300 mg per day
    Clinical noteBoard stated lower doses may be more reasonable in older adults (Board defined older adult as ≥65 years)
    Monitoring result (2nd quarter 2025)

    Required Provider Actions and Operational Requests

    Prior Authorization

    Step-through requirement for GLP/GIP and SGLT-2 (diabetes)

    For diabetes indications, GLP-1/GIP agonists and SGLT-2 inhibitors are subject to a step-through requirement; providers can indicate alternate non-diabetes uses on the request form to bypass step-through.

    Step Therapy

    Diabetes-specific step therapy for GLP/GIP — document indication to bypass

    GLP-1/GIP agents used for type 2 diabetes must follow the diabetes-specific step therapy (step-through) process; if prescribing for a non-diabetes indication, document that indication on the request form so the step-through may be bypassed.

    • Step-through applies for T2DM access to GLP-1/GIP agents.
    • Providers must indicate alternate indications on the prior authorization/request form to bypass step-through.

    Background and Scope

    The DUR minutes summarize targeted monitoring and interventions for several medication categories with safety or cost concerns. The Board identified cases that generated outreach for concurrent benzodiazepine–opioid use, recipients receiving > 90 MME daily, stimulant dosing above maximums, chronic opioid therapy without naloxone, GLP-1/GIP use in women of childbearing potential, pediatric atypical antipsychotic use, tramadol prescribing, biosimilar uptake, and select LAI antipsychotic transitions. Examples include six pediatric recipients receiving atypical antipsychotics under the indicated age and a single FFS recipient who received Invega Hafyera (subsequently determined not to require ongoing tracking). The Board requested further claims-level review, provider outreach for off-label LAI use, and continued quarterly tracking for many of these safety and utilization topics.

    Definitions and Clinical Thresholds

    inv-11: > 90 MME daily — definition reference for MME threshold
    > 90 MME daily — definitionDefined in the document as recipients receiving more than 90 Morphine Milligram Equivalent (MME) per day
    Denominator for monitoring121 unique recipients received an opioid during 2nd quarter 2025 (used for rate calculations)
    Board actionBoard requested continued tracking of patients receiving >90 MME for FFS and requested NHP benchmarking details
    inv-12: Chronic opioid therapy without naloxone — definition of identified recipients lacking naloxone co-prescription
    DefinitionRecipients on chronic opioid therapy identified without a naloxone prescription (chronic opioid therapy without naloxone)
    Monitoring result (2nd quarter 2025)

    Initial Therapy and Transition Criteria

    Oral-to-LAI transition

    Example initial therapy review:

    Oral aripiprazole prior to LAI: Claims review showed an example recipient started oral daily aripiprazole in 2017 and transitioned to a long-acting injectable formulation (Abilify Maintena) in 2024; the Board identified this as off-label pediatric LAI use and requested further provider outreach.

    Step Therapy Requirements

    Drug class / indicationStep therapy requirementHow to bypassNotes
    GLP-1/GIP agonists — Type 2 diabetes mellitus (T2DM)Step-through criteria required for diabetes indicationsProviders may indicate alternate uses on the prior authorization/request form to bypass step-through125 unique recipients used GLP/GIP agents for T2DM in 2nd quarter 2025; Board requested continued tracking
    GLP-1/GIP agonists — Weight lossNot subject to diabetes step-through for weight-loss indicationProviders should document indication on the request form to access without step-through53 unique recipients used GLP/GIP agents for weight loss in 2nd quarter 2025; Board requested continued tracking
    SGLT-2 inhibitors — Type 2 diabetes mellitus (T2DM)Step-through criteria required for diabetes indicationsProviders may indicate alternate/non-diabetes indications on the request form to bypass step-through108 unique recipients received an SGLT-2 medication in 2nd quarter 2025; Board requested continued tracking

    Quantity Limits and Dose Constraints

    inv-15: tramadol — quantity/limit value (300)
    Tramadol quantity limitLimit specified as 300 mg per day
    Population note6 unique recipients receiving tramadol identified during 2nd quarter 2025 (0.1% of FFS)
    BenchmarkComparison state showed 0.5% of their FFS population received tramadol during 2nd quarter

    Site-of-Care Observations

    Note

    Spravato (esketamine) not identified via pharmacy or physician-administered claims

    No Spravato pharmacy claims or physician‑administered/procedure code claims were identified for the quarter; providers and program staff may need alternative tracking approaches outside standard pharmacy or physician-administered claims.

    • Gainwell found zero Spravato claims billed via physician-administered claims or procedure codes.
    • Consider alternative monitoring methods since usual claim channels showed no activity.

    Biosimilar Monitoring

    Billing Rule

    Adalimumab biosimilar use identified — track prescriber/pharmacy substitution

    Two FFS recipients were identified receiving adalimumab biosimilars (Simlandi, Hadlima); the Board requested continued tracking and noted that use may reflect prescriber-specified biosimilar prescribing or pharmacy-level substitution.

    • Prescriber may have written for the biosimilar product specifically, or the pharmacy may have substituted the biosimilar for Humira.
    • EOHHS requested ongoing monitoring of prescriber-level utilization for potential substitution patterns.
    Policy Summary
    PayerExecutive Office of Health and Human Services
    PolicyDUR Board follow-up: monitored utilization and tracking (coverage criteria)
    Policy CodePolicy N/A
    Change TypeInformational / tracking update
    Effective DateN/A
    Next Review DateN/A
    Key ActionProviders must document prior oral therapy when requesting review of transitions to long-acting injectable antipsychotics (claims review requested).
    SourceLink
    On This Page
    Coverage and Monitoring CriteriaKey Coding ThresholdsRequired Provider Actions and Operational RequestsBackground and ScopeDefinitions and Clinical ThresholdsInitial Therapy and Transition CriteriaStep Therapy RequirementsQuantity Limits and Dose ConstraintsSite-of-Care ObservationsBiosimilar Monitoring
    6 unique recipients identified (0.1% of FFS population)
    Documentation Required

    Review claims to document prior oral therapy (e.g., Abilify Maintena ER)

    The Board requested Gainwell and Acentra to review claims histories (example: the Abilify Maintena ER case) to determine if an oral formulation was used initially; documentation of prior oral therapy should be obtained from claims review to assess off-label transitions.

    • Review claims to confirm prior use of oral aripiprazole before LAI initiation.
    • Use claims history documentation to evaluate potential off-label pediatric LAI use.
    Denial Risk

    Intervention case tracking — no automatic denial actions documented

    Interventions generated cases and provider responses were tracked for monitored criteria, but the minutes do not document any automatic denial triggers tied to these interventions.

    • 13 cases were created for chronic opioid therapy without naloxone with one provider response noted.
    • Response options on mailers remain in place; removal would affect all DUR letters.
    13 recipients identified and 13 cases created (denominator: 121 unique opioid recipients)
    Board decisionKeep current mailer response options and continue tracking; consider drill-down where concurrent CNS depressants are present