Drug Utilization Review (DUR) Board Meeting Minutes — Pharmacy Utilization and Prior Authorization Updates
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Minutes documenting DUR Board recommendations on medication safety and utilization affecting Medicaid medication management, including prior authorization and step therapy changes for long acting oxycodone and requests for patient-level reports.
Patients will no longer be exempt from prior authorization for long acting oxycodone; must fail preferred long acting agents before approval.
Coverage Criteria
A new prior authorization process for long acting oxycodone has been established. Under this change, patients will no longer be exempt from prior authorization even if they previously had taken the drug. Approval for long acting oxycodone now requires documented failure of preferred long acting agents prior to authorization.
Provider Actions and Prior Authorization
Prior authorization: failure of preferred long‑acting agents required
A new prior authorization process requires that patients fail preferred long-acting agents before long-acting oxycodone will be approved; patients who previously received long-acting oxycodone will no longer be exempt from prior authorization. Neighborhood plan prior authorization and monitoring for Suboxone® (buprenorphine/naloxone) was also noted.
- Patients will no longer be exempt from the prior authorization process if they previously had taken long-acting oxycodone.
- Approval of long-acting oxycodone requires documented failure of preferred long-acting agents.
Step therapy — long‑acting oxycodone
Step therapy requires that patients fail preferred long-acting opioid agents before long-acting oxycodone will be approved under the new prior authorization process.
- Documented trial and failure of preferred long-acting agents is required prior to approval of long-acting oxycodone.
Provide requested patient‑level reports to HID
HID must provide patient-level lists requested by the Board: include all patients with a hepatitis C diagnosis indicating current treatment status and evidence of antiretroviral use; lists of children taking atypical antipsychotics who are younger than the labeled age; lists of patients on Suboxone® with concurrent opioid use; and Connect Care Choice patient lists for review of recent antidepressant therapy.
- List of all patients with a hepatitis C diagnosis showing whether the patient has current treatment and evidence of antiretroviral therapy.
- List of children taking atypical antipsychotics who are less than the labeled age for those drugs.
- List of patients taking buprenorphine/naloxone (Suboxone®) who are concurrently taking other opioids; continue monitoring and send identified patient lists to the Department.
- Connect Care Choice patient list for evaluation of recent antidepressant therapy.
Denial risk — long‑acting oxycodone prior authorization
Patients will no longer be exempt from prior authorization for long-acting oxycodone; failure of preferred long-acting agents is required before approval. Providers who prescribe long-acting oxycodone without documented step therapy risk denial of coverage.
- Prior authorization denials can occur if the required failure of preferred long-acting agents is not documented.
- Existing patients previously receiving long-acting oxycodone are subject to the new prior authorization requirement and must meet step-therapy criteria.
Background
The DUR Board reviewed multiple medication safety and utilization issues affecting the Medicaid population. Topics discussed included long-term risks and monitoring for sedatives (notably triazolam), the use and prior authorization of long-acting narcotics, concerns about brand versus generic anticonvulsant switching and attendant liability, and development of criteria for smoking cessation product coverage. The Board requested targeted analyses from HID, including evaluation of patients chronically taking triazolam and reviews related to anticonvulsant prescribing patterns.
Definitions
Continuation Criteria
Hepatitis C continuous treatment
Board recommendation regarding hepatitis C treatment continuity
Step Therapy Requirements
| Step | Requirement | Coverage stance |
|---|---|---|
| 1 | Patient must fail preferred long‑acting opioid agents prior to approval of long‑acting oxycodone | Must fail preferred agents before approval |
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