CurrentExecutive Office of Health and Human ServicesPolicy N/A

Drug Utilization Review Board meeting minutes — coverage criteria for lock-in, RDUR interventions, and pediatric psychotropic monitoring

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Meeting minutes documenting the DUR Board discussions about lock-in criteria, controlled substances monitoring, pediatric antipsychotic and stimulant utilization, RDUR interventions and prescriber outreach affecting Medicaid Fee-for-Service recipients, prescribers, pharmacies, and DUR administrators.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDUR Board meeting minutes — lock-in and RDUR intervention criteria; pediatric psychotropic monitoring

Policy CodePolicy N/A

Change TypeInformational meeting minutes

Effective DateN/A

Next Review DateN/A

Key ActionHID will run alternative lock-in thresholds and provide pediatric antipsychotic duration data and prescriber response counts for RDUR outreach.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

131patients locked in to one pharmacy

222children <18 on antipsychotics (Q4 2014)

10,285stimulant prescriptions (2014)

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

Drug Utilization Review Board meeting minutes — coverage criteria for lock-in, RDUR interventions, and pediatric psychotropic monitoring

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Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDUR Board meeting minutes — lock-in and RDUR intervention criteria; pediatric psychotropic monitoring

Policy CodePolicy N/A

Change TypeInformational meeting minutes

Effective DateN/A

Next Review DateN/A

Key ActionHID will run alternative lock-in thresholds and provide pediatric antipsychotic duration data and prescriber response counts for RDUR outreach.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

131patients locked in to one pharmacy

222children <18 on antipsychotics (Q4 2014)

10,285stimulant prescriptions (2014)

2,130recipients on antipsychotics (2014)

6,445RDUR letters sent (2014)

36%overall provider response rate (2014)

Drug Utilization Review Criteria & Monitoring

Lock-In and RDUR Intervention Criteria

RDUR and Lock-In criteria and intervention logic described in meeting:

Lock-In identification: Recipient meets all: >=6 controlled-substance claims in a month AND claims originate from >=3 pharmacies AND prescriptions from >=2 prescribers6 claims for controlled substances from >=3 pharmacies and >=2 prescribers in one month

DUR Board requested HID run alternative thresholds (3, 4, or 5 controlled-substance claims/month) and to include single-fill small-quantity prescriptions in future results

RDUR prescriber outreach criteria examples: Recipient meets any of: >100 morphine milligram equivalents/day; concurrent oxycodone and a benzodiazepine; long-term short-acting opioid therapy without long-acting opioid>100 morphine milligram equivalents per day

For identified prescribers, RDUR letters were mailed and the number of prescriptions attributed to the prescriber was tracked for four months to assess changes; follow-up for non-responding prescribers was discussed

Pediatric psychotropic monitoring

Monitoring and requested follow-up regarding pediatric psychotropic use:

Pediatric antipsychotic duration request: Identify children <18 on any antipsychotic for >=180 days and provide their diagnoses>=180 days on antipsychotic

DUR Board asked HID to provide this data

Stimulant utilization findings: Of 1,825 recipients prescribed stimulants in 2014, 1,367 had non–FDA‑approved diagnoses based on paid medical claims (examples: pervasive disorder, intellectual disorder, learning problems, oppositional defiant disorder)N/A

Board requested the number of prescribers who received RDUR letters for stimulant + antipsychotic without an antipsychotic diagnosis and their responses

The DUR Board reviewed current Lock-In activity and noted there are 131 patients currently restricted to a single pharmacy under Medicaid Fee‑for‑Service. The Board discussed continuity of restrictions when a recipient enrolls in Managed Care and recommended that lock-in status follow the patient from Fee‑for‑Service into Managed Care. The minutes also indicate that each locked‑in patient is reviewed annually and that HID may recommend removal if the patient no longer meets criteria, but final removal is performed by the agency or program that implemented the lock‑in.

The current lock-in population includes recipients in an out‑of‑state treatment facility and those managed by the Connect Care program. The Board noted patients with other primary insurance are not currently locked in under Medicaid because Medicaid is not the primary payer of their claims.

Operational Thresholds & Coding Definitions

inv-04: Lock-In claims threshold — 6 claims for controlled substances from >=3 pharmacies and >=2 prescribers in one month

Lock-In claims threshold6 claims for controlled substances from >=3 pharmacies and >=2 prescribers in one month

Monthly detection windowCriteria applied to claims within a single calendar month

Inclusions requested for future runsBoard asked HID to include single‑fill small‑quantity prescriptions in future results

inv-05: High opioid dose threshold referenced — >100 morphine milligram equivalents per day

High opioid dose threshold>100 morphine milligram equivalents per day

Context of useUsed as one RDUR prescriber‑outreach criterion to identify recipients for letters

Prescriber & Program Actions

Prior Authorization

No prior authorization specified

No prior authorization requirements are stated in these DUR Board meeting minutes.

Step Therapy

Prospective utilization review requested for Invokana®

The Pharmacy & Therapeutics committee asked the DUR Board to perform a prospective review of utilization for the new SGLT2 agent Invokana® after it was approved as a preferred Medicaid formulary agent.

DUR Board to review utilization patterns after Invokana® addition to preferred formulary

Documentation Required

Program Background & Scope

The DUR Board routinely monitors medication utilization patterns to identify potentially unsafe or non–evidence‑based prescribing and to guide targeted interventions. Examples discussed in the minutes include identifying high‑risk prescribing that can trigger retrospective DUR (RDUR) prescriber outreach and monitoring programmatic measures such as Lock‑In status and pediatric psychotropic use.

When criteria identify potentially concerning patterns, the Board uses RDUR letters to notify prescribers and then tracks prescribing for subsequent months to assess change; lock‑in reviews are performed annually and HID can recommend unlocking when criteria are no longer met.

Formulary Changes & Prospective Review Requests

Policy action requested	Drug / class	Notes
Prospective review of utilization
Invokana® (canagliflozin) — SGLT2 anti-diabetic agent
Board requested HID provide a prospective review of utilization after Invokana® was approved as a preferred agent on the Medicaid formulary

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDUR Board meeting minutes — lock-in and RDUR intervention criteria; pediatric psychotropic monitoring

Policy CodePolicy N/A

Change TypeInformational meeting minutes

Effective DateN/A

Next Review DateN/A

Key ActionHID will run alternative lock-in thresholds and provide pediatric antipsychotic duration data and prescriber response counts for RDUR outreach.

SourceLink

On This Page

Follow‑up trackingPrescriptions attributed to identified prescribers were tracked for four months to assess change

inv-06: Alternative thresholds requested — 3, 4, or 5 controlled substance claims in a month (alternative formulas requested)

Alternative claim thresholds requested3 controlled‑substance claims in a month (alternative)

Alternative claim thresholds requested4 controlled‑substance claims in a month (alternative)

Alternative claim thresholds requested5 controlled‑substance claims in a month (alternative)

inv-07: Pediatric long-term therapy threshold request — >=180 days on any antipsychotic (requested data)

Pediatric long‑term antipsychotic threshold requested>=180 days on any antipsychotic (identify children <18 meeting this duration)

Requested accompanying dataProvide diagnoses for children under 18 meeting the >=180‑day threshold

Quarter referencedBoard reviewed antipsychotic use in children in Q4 2014 (222 children on antipsychotics)

inv-13: Lock-In criteria (as used in minutes) — Lock-In criteria: receiving 6 or more claims for controlled substances from 3 or more pharmacies and 2 or more prescribers in a month.

Lock‑In criteria (minutes)Receiving 6 or more claims for controlled substances from 3 or more pharmacies and 2 or more prescribers in a month

Board concernDiscussion whether the criteria is too liberal prompted request for alternative formulas

Data handling noteHID excluded one‑time small‑quantity opiate prescriptions originally but was asked to include them in future results

Track prescriber-level prescriptions after RDUR outreach

HID tracked the number of prescriptions attributed to prescribers for specific RDUR criteria and monitored those prescribing counts over the subsequent four months to assess whether prescribers changed prescribing habits after receiving RDUR letters.

Prescriptions attributed to prescribers for >100 MME/day, oxycodone+benzodiazepine, and long-term short‑acting opioid without long‑acting opioid were identified and tracked for four months.
Follow-up was discussed for prescribers who did not respond to RDUR letters to determine changes in prescribing and ongoing patient care.

Denial Risk

Lock‑in status and removal handled by placing agency

Patients may be restricted (locked-in) to a single pharmacy under the Medicaid Fee‑for‑Service program; lock-in removal is performed by the agency or program that placed the lock-in.

HID reviews each lock-in patient annually and can recommend unlocking if criteria are no longer met.
Recommendations noted that some locked-in patients are in out-of-state treatment facilities or managed by Connect Care; patients with other primary insurance are not locked in under Medicaid.