Drug Utilization Review Board — DUR meeting decisions (atypical antipsychotic PDL and utilization evaluations)
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Summarizes DUR Board meeting minutes detailing utilization reviews, recommendations for drug classes and products, prior authorization and preferred drug list decisions, and monitoring actions affecting Medicaid pharmacy management.
No material clinical or coverage changes in this revision.
Coverage and Monitoring Positions
Management and monitoring positions
Coverage and management positions described in the minutes include:
Monitoring of hospitalization rates for this population was recommended.
Soft edit recommended to avoid claim denial.
Special attention to concurrent injectable plus oral antipsychotic use; prioritize educational interventions for duplicate oral agents.
Respect confidentiality limits for federally treated methadone patients; consider lock-in for patients obtaining duplicate narcotics at several pharmacies.
HID to begin utilization evaluation in these areas.
As part of the October 2008 Preferred Drug List (PDL) changes, Abilify, Invega, and Zyprexa were designated as non‑preferred atypical antipsychotics. Patients who were already taking these non‑preferred agents on October 1, 2008 were grandfathered and may continue their therapy without prior authorization. This grandfathering applies only to existing users as of that date; new starts after October 1, 2008 must follow the preferred‑agent initiation rule unless a prior authorization is obtained.
The PDL change and grandfathering decision aim to balance access for established patients with formulary management for new therapy starts. Providers should document existing therapy dates when continuity of a non‑preferred atypical antipsychotic is clinically necessary to support continuation under the grandfathering provision.
Provider Requirements and Prior Authorization
Prior authorization may be obtained for non-preferred atypical antipsychotics when clinically justified
Prior authorization is available for non-preferred atypical antipsychotic agents when clinically justified; providers must obtain prior authorization for new starts of non-preferred agents after October 1, 2008 unless an exception is documented.
- Applies to Abilify, Invega, and Zyprexa as the non-preferred agents on the PDL.
- Existing users of non-preferred agents as of Oct 1, 2008 are grandfathered and may continue without prior authorization.
New atypical starts must begin with a preferred agent (PDL effective Oct 1, 2008)
For any patient initiating atypical antipsychotic therapy on or after October 1, 2008, the prescriber must start treatment with a PDL-preferred agent; new starts of non-preferred agents require prior authorization to be approved.
HID to provide duplicate-therapy data and notify prescribers/medical directors
HID will generate and provide comparative data on duplicate antipsychotic therapy rates and identify top prescribers; Community Mental Health Clinic Medical Directors and top prescribers will be notified with letters describing the duplicate-therapy issue.
- Data will compare Rhode Island duplicate therapy rates to other states contracting HID.
- Community Mental Health Clinic Medical Directors and top prescribers are to receive notification and continued monitoring is recommended.
Prior authorization required for Abilify, Invega, and Zyprexa for new starts unless justified
The non-preferred atypical antipsychotics named on the PDL (Abilify, Invega, Zyprexa) require prior authorization for new therapy starts after October 1, 2008 unless clinically justified and authorized.
- These three agents were designated non-preferred when atypicals were added to the PDL in October 2008.
- Patients already taking these non-preferred agents as of Oct 1, 2008 may continue without prior authorization (grandfathered).
Context and Rationale
The DUR Board minutes identify several clinical concerns relevant to medication safety and utilization management in the Medicaid population, including off‑label use, adherence, therapeutic duplication, dose optimization, and the risks associated with improper psychotropic and narcotic use. Specific examples noted were low adherence to anticonvulsants (which may increase risk of breakthrough seizures), duplicate long‑acting stimulant therapy, duplicate antipsychotic therapy including concurrent injectable plus oral formulations, and opioid prescribing in patients on Suboxone. The minutes also recommend monitoring outcomes such as hospitalization rates among patients taking atypical antipsychotics to ensure that formulary changes do not adversely affect clinical outcomes.
Key Definitions
Atypical Antipsychotics — Initial Therapy
Atypical antipsychotics — initial therapy
Atypical antipsychotic initiation rule
Existing users grandfathered.
Atypical Antipsychotics — Continuation and Grandfathering
Atypical antipsychotic continuation
Grandfathering and continuation rules for atypical antipsychotics
New starts require preferred agent or prior authorization.
Step Therapy and Preferred Agent Requirement
| Step | Requirement | Prior authorization |
|---|---|---|
| 1 | Patients starting new atypical antipsychotic therapy after October 1, 2008 must start with a preferred agent. | Prior authorization may be obtained for non-preferred atypical antipsychotic agents (Abilify, Invega, Zyprexa) if clinically justified. |
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