Drug Utilization Review (DUR) Board meeting recommendations and utilization reviews
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Minutes of the DUR Board meeting detailing utilization reviews, proposed prior authorization edits, lock-in program patient reviews, and surveillance recommendations affecting Rhode Island Medicaid pharmacy management and prescribers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Board Recommendations
Board recommendations and monitoring criteria
Board recommendations and follow-up actions to manage utilization and safety for specific scenarios:
Fourteen patients were sent warning letters in 2012 to date; five continue to over-utilize
One patient noted on buprenorphine without naloxone; mono-buprenorphine typically used in pregnancy
Prospective edit exists but can be overridden by pharmacist
Neighborhood Health Plan requires PA for 25 mg and 50 mg tablets but Board not in favor of PA
P&T requested ePA for pregnant women
The DUR Board discussed the use of low-dose quetiapine and noted that although the FDA has not approved quetiapine for low‑dose treatment of anxiety, some plans (e.g., Neighborhood Health Plan) require prior authorization for 25 mg and 50 mg tablets. The Board decided not to require prior authorization for low-dose quetiapine because of concern that a PA requirement could have the unintended consequence of increasing benzodiazepine use. The Board asked HID to evaluate and report back on the proportion of patients receiving < 200 mg per day at the next meeting.
The Board did not issue any blanket not medically necessary determinations. Discussions instead emphasized targeted utilization management approaches — maintaining DUR alerts for potential duplicate therapy, developing specific retrospective and prospective criteria (for example, to flag clonazepam used with another benzodiazepine), and pursuing focused prior authorization edits only where necessary. The Board’s approach favors utilization review, prescriber outreach, and selective prior authorization rather than broad NMN statements that could create access barriers.
Coding and Thresholds
Provider Actions and Prior Authorization Requirements
Prior authorization required for buprenorphine >24 mg/day
Require prior authorization for buprenorphine doses greater than 24 mg per day.
- Threshold: > 24 mg per day
Create PA criteria for lurasidone tied to pregnancy or prenatal vitamin use
Develop prior authorization criteria for lurasidone (Latuda®) that allow pregnant women access without standard PA; criteria should include a diagnosis of pregnancy or documentation of concurrent prenatal vitamin use in women under 45.
- P&T requested an electronic prior authorization pathway for non-preferred lurasidone to allow pregnant women access
- PA criteria to include pregnancy diagnosis or concurrent prenatal vitamins in women <45
No summary provided — placeholder inventory item
(No action text provided in source inventory.)
Respond to DUR intervention letters or expect escalation
Respond to DUR intervention letters when requested; prescribers who do not respond may be contacted by the Medicaid Medical Director and may be sent additional copies of the letters.
- Overall response rate noted at 31% (Sept 2011–Feb 2012)
- Top non‑responding prescribers to be asked why they did not respond and may be escalated to the Medical Director
Buprenorphine >24 mg/day PA (repeat recommendation)
Require prior authorization for buprenorphine doses greater than 24 mg per day (Board recommendation repeated).
- Board recommended doses >24 mg require prior authorization
- Review patients taking buprenorphine without naloxone to determine indication (e.g., pregnancy)
PA criteria for lurasidone to address pregnancy-related access
Develop PA criteria for lurasidone (Latuda®) that include pregnancy diagnosis or concurrent prenatal vitamin use in women <45 to permit electronic PA access for pregnant women.
- Latuda® has pregnancy category B and P&T requested ePA so pregnant women can access without standard PA
- Board requested a review of lurasidone use at the August meeting
Background and Policy Context
The DUR Board reviewed overall opioid and controlled substance utilization, including candidates for the Lock‑in program, patterns of buprenorphine prescribing (including mono‑buprenorphine use, which may reflect pregnancy management), and concerns about therapeutic duplication (notably benzodiazepine combinations). The Board noted that many DUR intervention letters for duplicate benzodiazepine therapy involve daytime versus nighttime benzodiazepine use or clonazepam used with another benzodiazepine, and requested verification that prospective DUR alerts flag these combinations. The Board emphasized continued monitoring, prescriber outreach, and targeted criteria development to mitigate inappropriate controlled‑substance use while avoiding unintended access limitations.
Definitions and Key Terms
Initial Prescribing Alerts and Criteria
Initial prescribing alerts
Considerations for initial prescribing and alerts
Intervention letters noted frequent use of daytime benzodiazepine plus a sedative benzodiazepine at night; new criteria requested
Continuation Monitoring and Follow-up
Continuation monitoring
Follow-up and monitoring items for patients on ongoing therapy
Five patients identified continuing to over-utilize after warning letters
Step Therapy and Electronic Prior Authorization
| Step | Requirement | Criteria to meet | Notes / Rationale |
|---|---|---|---|
| 1 | Electronic prior authorization pathway for non-preferred lurasidone (Latuda®) | Patient is pregnant OR female <45 years with documentation of concurrent prenatal vitamin use | P&T requested ePA so pregnant women can access lurasidone without standard prior authorization; lurasidone has pregnancy category B vs other antipsychotics category C; Board to develop PA criteria and review use at August meeting. |
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