CurrentExecutive Office of Health and Human ServicesPolicy N/A

Drug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria (Pharmacy & Specialty Drugs)

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Minutes summarizing DUR findings, benchmarking, follow-up actions, and tracking decisions for pharmacy and specialty drug use in the FFS Medicaid population.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDrug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria

Policy CodePolicy N/A

Change TypeTracking updates and targeted follow-up actions

Effective DateN/A

Next Review DateDec 13, 2022

Key ActionKepro to follow up in December on all active DUR tracking items and Gainwell to confirm PA enrollment requirements for weight loss medications.

SourceLink

POLICY UPDATE CHANGES

DUR follow-up interventions and tracking directed by the Board across multiple topics (benzodiazepine+opioid concurrent use, atypical antipsychotics under indicated age, >90 MME opioid use, stimulant max-dose exceedances, naloxone mailers, tramadol utilization, newer TD medications, buprenorphine MAT trends, weight loss drugs, post-MI medication gaps, hepatitis C therapy follow-up).

Board requested discontinuation of tracking for tramadol utilization and for buprenorphine MAT decline.

Weight loss medication prior authorization inquiry and class review: Gainwell to confirm whether PA requires enrollment in a weight loss management program; Board requested review of weight loss medications as a class and consideration of new policy.

2nd quarter 2022

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

Drug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria (Pharmacy & Specialty Drugs)

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

Know when Executive Office of Health and Human Services releases new policies or updates existing guidance.

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Minutes summarizing DUR findings, benchmarking, follow-up actions, and tracking decisions for pharmacy and specialty drug use in the FFS Medicaid population.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDrug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria

Policy CodePolicy N/A

Change TypeTracking updates and targeted follow-up actions

Effective DateN/A

Next Review DateDec 13, 2022

Key ActionKepro to follow up in December on all active DUR tracking items and Gainwell to confirm PA enrollment requirements for weight loss medications.

SourceLink

POLICY UPDATE CHANGES

Board requested discontinuation of tracking for tramadol utilization and for buprenorphine MAT decline.

2nd quarter 2022

Board Tracking and Coverage Decisions

DUR follow-up interventions and tracking

The Board directed continued tracking or discontinuation per topic; Kepro to follow-up in December for each active tracking item.

Concurrent benzodiazepine and opioid use: 5 recipients identified and reviewed; 5 cases created during 2nd quarter 2022 representing 0.01% of the FFS population; Board requested continued trackingconcurrent prescribing

Denominator: 295 recipients receiving benzodiazepines and 117 recipients receiving opioids; benchmark 0.5% in another state

Atypical antipsychotics under indicated age: 8 recipients identified during 2nd quarter 2022 accounting for 0.06% of the RI FFS pediatric population; Board requested continued trackingage below indicated

Benchmark ~2% in another state

>90 MME daily opioid use: 1 recipient identified and reviewed; 1 case created during 2nd quarter 2022 accounting for 0.002% of the RI FFS population; Board requested continued tracking> 90 MME/day

Denominator: 117 unique recipients received an opioid; benchmark ~0.1% in another state

Stimulant exceeds max dose: 20 unique recipients identified and 20 cases created during 2nd quarter 2022 representing 0.4% of the RI FFS population; Board requested continued tracking and medication review at next meetingexceeds max dose per criteria

Denominator: 420 recipients receiving stimulants; no recipients >=40 years with CVD diagnosis identified; Kepro to review concomitant medications for next meeting

Opioid recipients without naloxone: 5 recipients identified and 5 cases created during 2nd quarter 2022 with no responses to mailers; Board requested continuation of the mailer for Q3opioid without naloxone prescription

Denominator: 117 opioid recipients; Neighborhood reports 10% of their opioid recipients filled naloxone; Kepro to follow-up

Tramadol utilization: 10 unique recipients received 17 tramadol prescriptions during 2nd quarter 2022; Board requested discontinuation of tracking for tramadol utilizationtramadol claim

Tramadol comprised 8% of opioid claims vs 20% in benchmark state; Board discontinued tracking

Newer TD medications without TD diagnosis: 2 recipients received Ingrezza or Austedo during 2nd quarter 2022; Board requested development of DUR criteria to identify recipients receiving these agents without a supporting TD diagnosisreceipt of Ingrezza or Austedo without TD diagnosis

Kepro to meet with Gainwell to finalize criteria; continue tracking

Buprenorphine MAT pre/post COVID utilization: 521 recipients in 2019 vs 170 in 2021; Board requested discontinuation of tracking for buprenorphine MAT declinebuprenorphine MAT claim

Decline attributed to coverage changes and loss to follow-up; no recipients >24 mg/day identified in 2nd quarter 2022

ADA-recommended weight loss drugs in T2D and obesity: No patients identified with both T2D and obesity during 2nd quarter 2022; 12 recipients received liraglutide, orlistat, or semaglutide; Board requested review of weight loss medications as a class and follow-up on PA program enrollment requirementsdiagnosis: T2D + obesity

Gainwell to confirm whether FFS prior authorization requires enrollment in a weight loss management program; Kepro to develop a prescriber mailer pending follow-up; continue tracking

Post-MI medication utilization: 1 recipient identified with recent MI not on a beta blocker but receiving an ACEI; Board requested continued tracking and development of criteria to identify lack of ACEI post-MIrecent MI without beta blocker/ACEI

Neighborhood to share criteria parameters for Kepro to create a similar query; continue tracking

Hepatitis C medication utilization: 2 recipients received Mavyret during 2nd quarter 2022; Board requested follow-up to determine continuation of therapyMavyret claim

Kepro to follow-up on whether recipient 1 received an additional course and if recipient 2 continued therapy after movement to an MCO; continue tracking

The Board requested discontinuation of tracking for tramadol utilization. Kepro reported that 10 unique recipients received 17 tramadol prescriptions during the 2nd quarter of 2022, representing 8% of opioid claims in RI FFS compared with a 20% benchmark state; the Board confirmed no tramadol combination products are on the PDL and directed that tramadol criteria tracking be stopped. (Kepro previously identified one recipient at seizure risk from concurrent tramadol and amitriptyline, but no mailers were sent.)

The Board also reviewed buprenorphine MAT utilization and, after discussion of pandemic-era changes, follow-up care, Medicaid expansion effects, and access barriers, directed discontinuation of tracking for buprenorphine MAT decline. Neighborhood’s analysis noted a drop from prior years with many patients receiving single ED doses and not following up with outpatient care; no recipients were found to be receiving > 24 mg/day of buprenorphine in the 2nd quarter 2022. Kepro was not asked to continue monitoring this topic.

Clinical Thresholds and Dosing Parameters

CODING — Thresholds

Opioid daily dose threshold> 90 MME

CODING — Buprenorphine

Buprenorphine max daily dose> 24 mg/day; no recipients found >24 mg/day in 2nd quarter 2022

Requests and Action Items for Vendors and Plans

Prior Authorization

Confirm PA requirement for weight loss program enrollment

Board asked Gainwell to confirm whether FFS Medicaid prior authorization criteria for weight loss medications require enrollment in a weight loss management program; Gainwell follow-up was pending and Kepro was asked to develop a prescriber mailer pending that confirmation.

Gainwell to follow-up on whether PA criteria require program enrollment
Kepro to develop DUR mailer for prescribers pending Gainwell response

Step Therapy

Review weight loss medications as a class; consider utilization policy

The Board requested a class-level review of weight loss medications (Xenical, Qsymia, Contrave, Saxenda, Wegovy, Imcivree) and consideration of a new policy on appropriate utilization; no explicit step-therapy rules were specified in the minutes.

Class list: Xenical (orlistat), Qsymia (phentermine/topiramate ER), Contrave (naltrexone/bupropion ER), Saxenda (liraglutide), Wegovy (semaglutide), Imcivree (setmelanotide)

Meeting Minutes Summary

These DUR Board minutes summarize retrospective utilization reviews and follow-up actions across multiple medication classes for the Rhode Island FFS Medicaid population. Topics presented by Kepro included opioid-related measures (tramadol utilization, naloxone dispensing, and high-dose opioid use), stimulant dosing, atypical antipsychotic prescribing in pediatric recipients, tardive dyskinesia agents, buprenorphine MAT trends, weight loss therapies, and select specialty medications such as hepatitis C agents.

Benchmarking against another state and targeted case review were used to prioritize interventions; the Board directed continued tracking for some items (for example naloxone utilization) and discontinued tracking for others (including tramadol utilization and buprenorphine MAT decline), with Kepro to follow up on remaining action items at the next review.

Key Terms and Abbreviations

DEFINITIONS

MME (Morphine Milligram Equivalent)Used as the threshold for opioid dosing risk; > 90 MME/day flagged in DUR review

DEFINITIONS

Tardive dyskinesia (TD)Newer TD medications referenced: Ingrezza (valbenazine) and Austedo (deutetrabenazine)

Weight Loss Medication Class Review and Step Considerations

Requested review action	Details / board comments	Follow-up assigned
Review weight loss medications as a class
Board asked to review the class separately from ADA‑recommended agents; noted high demand and that these medications may warrant a new policy on appropriate utilization. Class examples listed: orlistat (Xenical), phentermine/topiramate ER (Qsymia), naltrexone/bupropion ER (Contrave), liraglutide (Saxenda), semaglutide (Wegovy), setmelanotide (Imcivree).
Kepro to develop a DUR mailer for prescribers targeting patients receiving these weight loss medications (pending Gainwell follow-up). Continue tracking utilization; Kepro follow-up scheduled for December.