Drug Utilization Review (DUR) Board Meeting Minutes (Draft)
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Draft minutes from a DUR Board meeting summarizing utilization reviews, committee recommendations, monitoring activities, and requests for data analysis that affect Medicaid pharmacy management and prior authorization practices.
No material clinical or coverage changes in this revision.
Coverage Criteria Overview
Patients discharged from the hospital on a newer oral anticoagulant may be continued on that agent when clinically indicated; prior authorization will be approved in those discharge scenarios. Otherwise, newer oral anticoagulant agents require prior authorization, and warfarin is the only preferred oral agent without prior authorization requirements noted in this review. These requirements reflect the DUR Board and P&T Committee recommendations on anticoagulant utilization and monitoring costs.
Required Provider Actions and Prescriber Notifications
Prior authorization required for newer oral anticoagulants; hospital-discharge exception
Prior authorization is required for newer oral anticoagulant agents; however, if a patient is discharged from the hospital on a newer oral anticoagulant, prior authorization may be approved to allow continuation of that medication.
Statin preference: switch non‑preferred high‑potency statins to preferred alternatives
The P&T Committee recommends using generic Lipitor® as the preferred higher-potency statin and switching patients on non-preferred high‑potency statins (including non-preferred Crestor® except where allowed to continue) to preferred alternatives.
- P&T noted availability of generic Lipitor® making it the preferred higher-potency statin.
- Prescribers should switch patients on non-preferred high-potency statins to preferred options to align with the P&T recommendation.
Prescriber notification prior to Crestor® status change
HID will notify prescribers in advance of the formulary change for Crestor® by sending letters prior to the status change so that therapy is not interrupted.
- Planned prescriber letter to be sent prior to the change, potentially as early as January 1, 2013.
Warfarin is the preferred oral anticoagulant; newer agents require PA
Warfarin remains the only preferred oral anticoagulant; newer oral anticoagulant agents require prior authorization and will be subject to PA processes.
- Providers should expect to obtain prior authorization for newer oral anticoagulants when prescribing, unless continuing therapy after hospital discharge per the PA exception.
Patients on non‑preferred Crestor® must be switched except 40 mg continuations
When Crestor® is changed to non‑preferred status, patients taking the drug must switch to another statin except for those currently on the 40 mg dose who are allowed to continue.
- Approximately 30 patients were identified with claims for Crestor® and prescribers will be notified before the change.
- Patients on 40 mg Crestor® may remain on therapy; all other Crestor® patients should be switched to another statin.
Step Therapy and Switching Requirements
| Patient group | Action required | Prescriber notification | Coverage status |
|---|---|---|---|
| Patients currently taking Crestor® at any dose except 40 mg | Must switch to another statin when Crestor® is changed to non-preferred | HID will send letters to prescribers prior to the change in status (change could be as early as January 1, 2013) | Non-preferred (switch required) |
| Patients currently taking Crestor® 40 mg | May continue on Crestor® (no switch required) | HID will notify prescribers prior to the change in status | Preferred for continuation (40 mg allowed) |
Background and DUR Board Review
The DUR Board reviewed multiple utilization concerns and committee recommendations across therapeutic areas. Topics discussed included antipsychotic use in children and antipsychotic prescribing for patients >65 with dementia, opioid and other controlled-substance utilization with identification of potential lock-in candidates, anticoagulant utilization and the costs of warfarin laboratory monitoring, and impending formulary status changes for high-cost agents such as Crestor®. The Board requested additional analyses stratified by age and gender and asked that HID/HP identify and evaluate patients on specific agents for up to 12 months to assess diagnoses and safety events.
Definitions
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