Drug Utilization Review Board Meeting Findings and Recommendations
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Minutes from the Rhode Island DUR Board meeting summarizing reviews of drug class utilization, retrospective DUR interventions, and program updates affecting Medicaid pharmacy management and prior authorization considerations.
No material clinical or coverage changes in this revision.
Coverage Findings
The Board determined that patients who appear clinically stable on their current therapy should not be the subject of retrospective intervention letters solely for black box warnings or similar alerts. In practice, this means established, stable regimens were not targeted for intervention correspondence unless a new or changed clinical concern was identified that warranted outreach.
Board Recommendations & Provider Impacts
New product-specific criteria reviewed
New product-specific prior authorization criteria for Avandia (rosiglitazone), Actos (pioglitazone), and high‑dose Vyvanse (lisdexamfetamine) were reviewed and may result in forthcoming authorization requirements or changes to existing criteria; providers should expect updates to PA rules for these products.
Utilization review may lead to limits or interventions
The DUR Board recommended evaluating utilization of antibiotics, triptans, and sedatives and may impose actions based on that review, including quantity limits, intervention letters recommending alternative or prophylactic therapies (e.g., migraine prophylaxis), or provider education/outreach.
- Triptans: evaluation may lead to quantity limits or intervention letters recommending migraine prophylaxis for patients using excessive quantities.
- Sedatives: consider avoiding abrupt quantity limits for long‑term users; dosage reductions and provider education are recommended.
- Antibiotics: utilization will be evaluated to identify areas for improvement and develop interagency plans to address inappropriate use.
Transition to NPI for prescriber identification
Prescriber identification is transitioning to use of National Provider Identifier (NPI); about 90% of Rhode Island pharmacies are using NPI now, but DEA numbers will continue to be used until a crosswalk between DEA and NPI is available.
- Providers should be prepared for NPI-based identification in pharmacy and prior authorization workflows as adoption increases.
- Operational notes: DEA numbers remain acceptable until the DEA→NPI crosswalk is implemented.
Send intervention letters for new black box interaction risks
Intervention (alert) letters are recommended to notify prescribers when potential drug‑drug or drug‑disease black box interactions are first noted based on changes in a patient’s therapy; prescribers of patients who appear stable on current therapy were not previously sent these letters but letters are advised when interactions are newly identified.
- Send alert letters at first identification of potential black box interactions resulting from therapy changes.
- Do not routinely send letters to prescribers of patients who appear stable on current therapy unless a change creates a new interaction risk.
Meeting Background & Scope
The DUR Board reviewed utilization patterns across multiple drug classes to identify inappropriate use and opportunities for programmatic response. Key topics included long-term use of sedatives, where abrupt quantity limits were cautioned against because of withdrawal risk and where gradual dosage reductions and provider education were recommended; evaluation of triptan utilization to determine whether actions such as quantity limits or intervention letters recommending migraine prophylaxis are needed; and review of low-dose quetiapine use across a range of psychiatric and related diagnoses. These findings informed potential provider outreach, targeted education (including inviting top prescribers to continuing education), and consideration of utilization management measures where clinically appropriate.
Key Definitions
Sedative & Initial Therapy Considerations
Sedative therapy considerations
Covered when ALL of the following management considerations are addressed:
If limits are implemented, allow tapering schedules to prevent withdrawal; identify top prescribers for outreach and education
Blue Cross RI has initiated provider educational programs; similar outreach is recommended for Medicaid prescribers
Tapering should be individualized to minimize withdrawal risk
Board recommended evaluating sedative utilization as part of broader DUR activities
Step Therapy & Utilization Management
| Recommended Evaluation / Action | Rationale / Notes | Targeted Products / Classes | Implementation Consideration |
|---|---|---|---|
| Review and consider new product-specific prior authorization criteria | |||
| New criteria for Avandia and Actos were reviewed; criteria for potential high-dose Vyvanse (new ADHD drug) were discussed, indicating forthcoming or considered authorization changes. | |||
| Avandia (rosiglitazone), Actos (pioglitazone), Vyvanse (lisdexamfetamine) high-dose | |||
| Draft specific prior authorization criteria where appropriate and share recommendations with the P&T Committee; monitor for adverse-event information to inform criteria. |
Quantity Limit Considerations
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