DraftExecutive Office of Health and Human ServicesPolicy N/A

DRAFT Drug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria (pharmacy program activities)

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Draft minutes documenting DUR Board discussions and recommendations about pharmacy program activities (lock-in program, prescriber outreach, opioid and antipsychotic utilization, low-dose quetiapine, non-preferred/high-cost drugs) that affect Rhode Island Medicaid managed care and fee-for-service medication management processes and stakeholders.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDRAFT Drug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor administrative update (no material changes)

Effective DateN/A

Next Review DateDec 11, 2012

Key ActionIdentify prescribers with outlying opioid prescribing for Medical Director follow-up and consider prescriber outreach rather than immediate coverage restrictions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19warning letters (Q1–Q2 2012)

5recommended for lock-in (Q1–Q2 2012)

31%overall DUR letter response

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DraftExecutive Office of Health and Human ServicesPolicy N/A

DRAFT Drug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria (pharmacy program activities)

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Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDRAFT Drug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor administrative update (no material changes)

Effective DateN/A

Next Review DateDec 11, 2012

Key ActionIdentify prescribers with outlying opioid prescribing for Medical Director follow-up and consider prescriber outreach rather than immediate coverage restrictions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19warning letters (Q1–Q2 2012)

5recommended for lock-in (Q1–Q2 2012)

31%overall DUR letter response

Coverage Criteria and DUR Recommendations

Lock-in and review criteria

Processes discussed and recommended responsibilities:

Lock-in recommendation workflow: HID screens patients for controlled substance overuse; intervention letters are sent to prescribers; 3-6 months after letters, patient drug history profiles are re-reviewed; the HID lock-in review committee may recommend lock-in; because the State Medicaid Pharmacist position is vacant, HID recommendations have been forwarded to HP; the Medicaid Medical Director must review each case prior to final lock-in due to patient appeal rights.

Board discussed blinded DUR Board review of recommended cases and example automated lock-in criteria used in Maryland; HID lock-in committee includes clinical pharmacists and a social worker.

Board review vs Medical Director: The DUR Board may perform an initial summary-level review (number of controlled drug claims, number of pharmacies, number of prescribers) but the Medicaid Medical Director is required to review each case recommended for lock-in.

Other states vary: Maryland uses DUR Board blinded review and automatic criteria; Arkansas and Connecticut leave final decision to the State Medicaid Pharmacist.

Prescriber review criteria

Prescriber-level review triggers discussed:

Prescriber outlier detection: Identify prescribers whose long-term short-acting opioid prescribing or duplicate long-acting opioid use differs by more than 2 standard deviations from the average prescriber for potential Medical Director review.>2 standard deviations

HID will identify these prescribers; Board suggested contacting prescribers who do not respond to letters for feedback to improve outreach; review of future prescribing patterns could measure impact.

Quetiapine (low-dose) guidance

Quetiapine prescribing observations and stance:

Low-dose quetiapine use: Low-dose quetiapine (<200 mg/day) is common (20–30% of patients in monthly DUR cycles); dispensing pharmacists receive non-mandatory low-dose alerts; the Board did not support restricting low-dose use because it is considered appropriate for PTSD and for patients with anxiety and coexisting substance abuse and restriction could increase benzodiazepine use.<200 mg/day

Board recommended identifying patients on quetiapine who also take medications for diabetes and alerting prescribers to potential metabolic adverse effects and to consider alternate agents if clinically appropriate.

Antipsychotic review

Antipsychotic monitoring recommendations:

Antipsychotics in children and long-term care: Review summaries of antipsychotic use in children at every DUR Board meeting; consider mailing the CMS bulletin to prescribers of antipsychotics in children under FDA-approved ages; review antipsychotic use in long-term care patients (many are dual-eligible and covered by Medicare Part D).

States are encouraged to reduce inappropriate antipsychotic use; CMS goal to reduce antipsychotic use in long-term care by 15% by end of 2012; some states require prior authorization for antipsychotics in children under labeled ages.

High-cost / non-preferred drug strategy

Approach to non-preferred/high-cost drugs:

High-cost non-preferred drug outreach: Evaluate drugs with the highest cost per claim (including biologic and other high-cost non-preferred agents) and determine which are non-preferred; consider contacting prescribers with intervention letters to recommend preferred alternatives where clinically appropriate rather than implementing immediate coverage restrictions.

Board recommended determining which high-cost agents are non-preferred and suggested prescriber outreach; recognize continuity-of-care issues for patients discharged on non-preferred hospital formulary agents.

The DUR Board discussed the status of triazolam and confirmed that triazolam is no longer covered by the Medicaid Program. The source data show no claims have been processed since July 2, 2012, and the Health Information Division (HID) will continue to monitor for any remaining refill claims associated with prior authorizations.

Coding and Clinical Thresholds

Long-term short-acting opioid use — threshold / key-value note

Threshold> 90 days

ContextApplies to patients utilizing short-acting opioids for greater than 90 days as identified by HID screening and targeted with intervention letters to prescribers.

Action TriggerPrescribers of patients meeting this threshold should be identified and referred to the Medicaid Medical Director for follow-up.

Related concernsBoard emphasized evaluating appropriate opioid prescribing due to increases in deaths associated with opioid use.

Provider Impact and Required Actions

Prior Authorization

Prior authorization required for some non-overridable duplicate opioid edits

Some managed care duplicate-opioid therapeutic duplication edits cannot be overridden by the dispensing pharmacist and require prior authorization; methadone is considered a long-acting opioid for purposes of these edits.

Step Therapy

High-cost non-preferred agent review and prescriber outreach (no new step therapy)

No formal step-therapy mandates were enacted. The Board recommended identifying high-cost non-preferred agents (highest cost per claim, including biologics) and contacting prescribers for possible substitution to preferred agents rather than immediate coverage restriction.

Evaluate drugs with highest cost per claim and determine which are non-preferred.
Consider prescriber outreach (intervention letters) to recommend preferred alternatives where clinically appropriate.

Background and Meeting Context

The DUR Board reviewed several program topics and ongoing activities relevant to pharmacy utilization management. Key areas included: monitoring antipsychotic use in children and long-term care populations, evaluating low-volume use of non-preferred agents (for example, lurasidone/Latuda®), identifying high-cost non-preferred drugs for possible prescriber outreach, and continuing surveillance of controlled-substance prescribing patterns as part of lock-in and outreach processes.

Specifically, the Board recommended that summaries of antipsychotic use in children be reviewed at every DUR meeting and suggested distributing the CMS bulletin to prescribers of antipsychotics for children under FDA-labeled age limits. The Board also asked HID to assess which high-cost drugs are non-preferred and consider prescriber contact to encourage clinically appropriate switching to preferred agents where feasible.

HID presented utilization counts showing very low uptake of some non-preferred agents in the first half of 2012 (for example, 16 patients with claims for lurasidone (Latuda®)), and the Board concluded no immediate follow-up was required for those specific products while endorsing continued monitoring and targeted outreach when drug cost and non-preferred status warrant it.

Definitions and Program Terms

Lock-in — program definition and workflow

DefinitionA program restricting a patient to a single pharmacy when screening indicates potential overuse of controlled substances after intervention letters fail.

ProcessHID screens patients, sends intervention letters to prescribers, re-reviews drug histories 3–6 months later, and the HID lock-in committee may recommend lock-in.

Review responsibilityMedicaid Medical Director must review each case recommended for lock-in prior to final lock-in because patients have appeal rights.

Committee compositionHID lock-in committee includes clinical pharmacists and a social worker; historically recommendations were sent to the State Medicaid Pharmacist but were forwarded to HP while the position was vacant.

Long-acting opioid (for DUR edits) — definition

Definition

Step Therapy and High-Cost Agent Table

Step	Policy summary	Board action / recommendation
1
No formal step-therapy mandates were enacted for DUR Board policy during this meeting; the Board focused on reviewing high-cost, non-preferred agents rather than implementing immediate coverage restrictions.
Evaluate drugs with the highest cost per claim (including biologics) to determine which are non-preferred and consider prescriber outreach (intervention letters) to encourage preferred alternatives where clinically appropriate; discuss findings at future DUR meetings (December meeting noted).