CurrentExecutive Office of Health and Human ServicesPolicy N/A

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

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Summarizes the Rhode Island EOHHS Drug Utilization Review (DUR) Board meeting discussions, utilization reviews, follow-up items, and tracking requests affecting Medicaid fee-for-service (FFS) recipients and program stakeholders.

Policy Summary

PayerExecutive Office of Health and Human Services

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

Policy CodePolicy N/A

Change TypeInformational — tracking and follow-up items

Effective DateN/A

Next Review DateN/A

Key ActionContinue quarterly tracking for multiple measures (e.g., concurrent benzodiazepine-opioid use, >90 MME, stimulant max-dose, GLP-1/GIP utilization) and report follow-up findings in September.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

June 10, 2025meeting date

10:31–11:55meeting times

Quarterlytracking cadence

≥9follow-up topics

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

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

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Policy Summary

PayerExecutive Office of Health and Human Services

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

Policy CodePolicy N/A

Change TypeInformational — tracking and follow-up items

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

June 10, 2025meeting date

10:31–11:55meeting times

Quarterlytracking cadence

≥9follow-up topics

Coverage Criteria Summary

The meeting minutes do not list any formal or explicit coverage exclusions. The Board did request that Acentra remove from presented biosimilar lists any agents not yet available on the U.S. market (example cited: Erelzi), but the minutes do not state that those agents are covered or excluded by policy. The document also notes that Acentra’s biosimilar list is FDA-sourced and includes products that have U.S. approval even if they are not yet marketed; no exclusion language or coverage-denial rules were provided in the minutes.

Separately, the Board discussed tracking and reporting for several drug classes (notably GLP-1/GIP and SGLT-2 agents) and requested continued quarterly monitoring and targeted interventions where appropriate, but did not record any specific coverage denials, prior authorization requirements, or explicit exclusion criteria tied to those classes in these minutes.

Key Coding / Thresholds

Opioid days' supply flag

Opioid days' supply threshold>= 60 days (criteria flag for chronic opioid therapy without naloxone)

ContextUsed to flag recipients receiving chronic opioid therapy without concurrent naloxone provision for targeted mailers and follow-up

Denominator referenced99 unique recipients received an opioid during 1st quarter 2025 (used in related analyses)

High opioid dosing threshold (MME)

High opioid dosing threshold> 90 MME daily

UseThreshold used to identify recipients for intervention and continued tracking (3 recipients identified in 1st quarter 2025)

Benchmarking noteComparable state benchmark ~0.1% of population exceeding 90 MME in 1st quarter

MME definition — Morphine Milligram Equivalent

DefinitionMME = Morphine Milligram Equivalent

PurposeStandardized measure to compare opioid potency for dosing thresholds (used to define > 90 MME daily)

Application in documentMME referenced in identifying recipients for intervention (3 recipients > 90 MME in 1st quarter 2025)

Provider Actions and Meeting Decisions

Prior Authorization

Active review: GLP‑1/GIP and SGLT‑2 utilization (concurrent use & statin checks)

Acentra reported that active review criteria are in place for GLP-1/GIP agents used concurrently with other diabetic medications and that diabetic patients are being checked for statin therapy per evidence-based guidelines; providers should expect these drug-class specific reviews to continue for RI FFS recipients and that concurrent-use and statin-status may be assessed during utilization reviews.

Active review of GLP-1/GIP use with other diabetic medications due to hypoglycemia risk
Statin therapy checks for diabetic patients per evidence-based guidelines (SGLT-2 and related reviews)

Step Therapy

Continuation monitoring for GLP‑1/GIP (chronic use implications)

The Board highlighted concern about chronic/continued use of GLP‑1/GIP agents — noting weight‑loss benefit requires continued treatment — and requested reporting on whether the same recipients continue quarter over quarter; providers should be aware monitoring and continuation tracking for chronic use will be part of ongoing surveillance.

Board Role and Scope Background

The Drug Utilization Review (DUR) Board reviews prescribing patterns and utilization for Rhode Island Medicaid fee-for-service (FFS) recipients with a primary focus on patient safety and appropriate use. Topics tracked and discussed in these minutes include concurrent high-risk medication combinations (for example, benzodiazepines with opioids), high opioid dosing (noted elsewhere as > 90 MME daily), naloxone provision, stimulant maximum-dose concerns, antipsychotic use in pediatric populations, and monitoring of emerging high-cost therapies such as GLP-1/GIP and SGLT-2 agents.

The Board uses quarterly benchmarking and targeted interventions (provider mailings, tracking) to address safety and utilization gaps. For GLP-1/GIP and SGLT-2 agents, the Board focused on separating utilization by indication (T2DM vs weight loss), assessing chronic/continuation use, and ensuring evidence-based comanagement (for example, statin therapy in diabetic patients). The minutes emphasize continued tracking and follow-up rather than immediate changes to coverage policy.

Key Definitions

MME (Morphine Milligram Equivalent)

TermMME (Morphine Milligram Equivalent)

Referenced threshold> 90 MME daily used as an intervention trigger

Role in monitoringUsed by DUR Board to benchmark high-dose opioid use and guide follow-up reporting

GLP-1/GIP definition — class and indication note

ClassGLP-1/GIP agonists

Indications notedGrouped by indication for type 2 diabetes mellitus (T2DM) versus weight loss (separate utilization tracking)

Program actions

New Starts / Initiation Tracking

New starts monitoring

Track initiation events and follow-up until coverage termination or continued receipt is confirmed.

Invega Hafyera initiation: One unique recipient newly started therapy in November 2024 transitioning off Invega Trinza; Board requested tracking to confirm whether a second dose is received and whether the recipient remains covered by FFS.

Acentra and Gainwell to verify FFS coverage termination prior to stopping tracking

Continuation / Chronic Use Tracking

GLP-1/GIP continuation tracking

Monitor persistence and chronic use for GLP-1/GIP agents where ongoing therapy is expected to maintain clinical effect.

GLP-1/GIP continuation monitoring: Board requested reporting on whether the same recipients continue utilization quarter over quarter and highlighted that continued/chronic use is needed to maintain weight-loss effects.

Acentra to report continuation data at next meeting and continue targeted interventions (e.g., letters for women of childbearing potential)

Concurrent-therapy review: Acentra confirmed active criteria are being used to review GLP-1/GIP medications used concurrently with other diabetic medications because of increased hypoglycemia risk.

Continue tracking and apply existing concurrent-use criteria for RI FFS recipients

Step Therapy / Active Review Tables

Criteria / Monitoring Item	Description	Action / Status
Concurrent use with other diabetic medications
Acentra confirmed criteria are active and reviewed for RI FFS recipients to identify GLP-1/GIP agents used concurrently with other diabetic medications due to increased hypoglycemia risk.
Continue review and tracking

Site-of-Care Tracking

Note

Site‑of‑care unchanged — nursing home vs home tracking continues

The Board did not change site‑of‑care coverage; tracking will continue to report nursing home versus home‑based recipient counts and targeted actions may focus on home‑based recipients.

No site‑of‑care coverage changes specified for FFS.
Board requested reporting of unique recipients residing in nursing homes and requested a specialty mailer targeting home‑based recipients when applicable.

Biosimilar Product Notes

Billing Rule

Adalimumab/biosimilar list — remove agents not on market; Prime may substitute

Acentra presented lists of cytokine and CAM biosimilars and the Board requested removal of agents not yet available on the U.S. market; the Board also noted Prime Therapeutics may substitute clinically similar, more cost‑effective biosimilars between P&T reviews.

Board asked to remove agents not currently available on market (example: Erelzi).
Prime Therapeutics may substitute clinically similar, cost‑effective biosimilars for originals between P&T class reviews.