Drug Utilization Review (DUR) Board meeting decisions and recommendations
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Minutes from the DUR Board describing PDL decisions, proposed quantity limits, prior authorization practices, data review requests, and programmatic initiatives affecting Medicaid pharmacy management in Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Decisions and Criteria
Coverage decisions and recommended criteria
Board decisions and coverage-related criteria discussed
HID to alert prescribers and implement prior authorization for non-preferred brands effective January 15, 2008; exceptions noted.
Most other plans and states have limits.
No change recommended.
Board recommended activation and referral option.
Suggested provider referral and quantity limit development.
The DUR Board reviewed current practices for anticonvulsant prescribing and confirmed that prior authorization and medical justification remain required for any brand-name anticonvulsant that has a generic equivalent. The Board recommended no change to the existing prior authorization process for these agents.
Provider Actions and Authorization Requirements
Prior authorization for non-preferred and branded anticonvulsants
Non-preferred brand statins and antidepressants will require prior authorization beginning January 15, 2008. In addition, brand-name anticonvulsants that have a generic equivalent continue to require prior authorization with medical justification.
- Prior authorization effective for non-preferred statins and antidepressants on Jan 15, 2008.
- Brand-name anticonvulsants with generic equivalents remain subject to prior authorization and medical justification.
Preferred generics expected first-line
For new prescriptions, generics are designated as the preferred first-line agents for lipid‑lowering drugs (statins) and antidepressants; prescribers should expect that non-preferred branded products will require prior authorization after the PDL change.
- Generic statins and generic antidepressants selected as preferred on the PDL.
- Non-preferred branded agents will require prior authorization (see effective date Jan 15, 2008).
- Patients already on certain branded agents (e.g., Lipitor 80mg, any dose of Crestor, Cymbalta, Lexapro) may continue without PA per continuation exceptions.
Documentation & data review
HID was requested to review pharmacy claims data before and after January 15, 2008 to determine if patients on non‑preferred agents were switched to preferred agents and to evaluate prior authorization denials and wait times.
- Analyze pharmacy data before and after Jan 15, 2008 (PDL implementation date for statins and antidepressants).
- Report on switches from non-preferred to preferred agents and on PA denials and wait times.
Prior authorization triggers
Non-preferred brand statins and antidepressants trigger prior authorization as of January 15, 2008; branded anticonvulsants with a generic equivalent continue to require prior authorization and medical justification—failure to obtain PA may result in non‑coverage.
- PA requirement for non-preferred statins and antidepressants effective Jan 15, 2008.
- Ongoing PA and medical justification required for brand-name anticonvulsants that have generic equivalents.
Initial Therapy Preference and Requirements
Initial therapy preference
For new prescriptions, preferred generics are intended as first-line agents.
Prescribers to be alerted that non-preferred brands will require prior authorization after January 15, 2008.
Continuation on Specific Branded Agents
Continuation on specific branded agents
Allow continuation of certain branded agents for established patients without prior authorization.
Step Therapy and Preferred Agents
| Drug class | Preferred agents (first-line) | Non-preferred (requires prior authorization) | Continuation exceptions (no PA required) | Effective date for PA |
|---|---|---|---|---|
| Statins | Generic statins (preferred) | Branded statins (non-preferred) | Patients currently taking Lipitor 80mg and any dose of Crestor may continue without prior authorization. | January 15, 2008 |
| Antidepressants | Generic antidepressants (preferred) | Branded antidepressants (non-preferred) | Patients currently taking Cymbalta and Lexapro may continue without prior authorization. | January 15, 2008 |
Coding and Dose Limits
Proposed Quantity Limits
Definitions and Key Terms
Background and Board Review
The Board reviewed the impacts of the Preferred Drug List (PDL) after approximately one year in effect and discussed targeted interventions to monitor and limit use of costly or potentially inappropriate therapies. Topics included evaluation of PDL effects on utilization and medical costs before assessing prescriber-level compliance, targeted prescriber outreach tied to specific patient interventions (for example, attaching revised guidelines when sending intervention letters), consideration of criteria for asthma-related prescribing patterns, and activation of new criteria to identify non-adherence to antiretroviral therapy with potential referral to case management.
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