CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

High Risk Medications (HRM) prior authorization for patients 70+

This policy governs prior authorization requirements for a list of high-risk medications (HRMs) when prescribed to patients 70 years of age or older for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHigh Risk Medications (HRM) prior authorization for patients 70+

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document prescriber acknowledgement that benefits outweigh risks for patients aged 70 and older.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

70+age threshold for prior authorization

multipleclasses of high-risk medications listed

AGS Beersclinical guidance referenced

Coverage Criteria

Prior Authorization Coverage Criteria

Covered when ALL of the following are met

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Age: Patient is 70 years of age or older70 years

Policy applies only to patients 70+

Medication Listed as HRM: Requested drug is included in the policy's list of high-risk medications (per lists in document chunks 0 and 1)listed medication

See coding module for enumerated products

Prescriber acknowledgement: Prescriber acknowledges that the benefit of therapy outweighs the potential risks for this patient as identified by the American Geriatrics Societyacknowledgement present

Required documentation per coverage criteria

Listed High-Risk Medications and Dosing Rules

Listed High-Risk Medications (by therapeutic class)mixedCovered

carbinoxamine maleate	antihistamine
clemastine fumarate	antihistamine
cyproheptadine hydrochloride	antihistamine
dexchlorpheniramine maleate	antihistamine
diphenhydramine (oral)	antihistamine
hydroxyzine hydrochloride	antihistamine
hydroxyzine pamoate	antihistamine
promethazine hydrochloride	antihistamine/antiemetic
promethazine/phenylephrine	combination antihistamine/decongestant
benztropine mesylate (oral)	antiparkinson (oral dosage form only)

1–10 of 47

1/5

Dose Thresholds / ApplicabilitymixedCovered

digoxin	applies to > 0.125 mg daily
doxepin (capsules, tablets, solution)	applies to > 6 mg daily

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required for Listed High-Risk Medications

Requests for listed high-risk medications (HRMs) are subject to prior authorization when the patient is 70 years of age or older. Prior authorization applies only to patients aged 70+. Requests for these listed HRMs for patients under the age threshold do not meet this specific prior authorization rule.

Applies to listed HRMs only
Age threshold: >= 70 years

Documentation Required

Prescriber Risk–Benefit Acknowledgement and Documentation

The prescriber must acknowledge that the benefit of therapy with the prescribed medication outweighs the potential risks for this patient, consistent with the American Geriatrics Society Beers Criteria. Documentation of the prescriber’s risk–benefit acknowledgement must be provided with the prior authorization request.

Reference: American Geriatrics Society Beers Criteria
Prescriber must provide risk–benefit acknowledgement and supporting documentation

Step Therapy

No step therapy requirements are specified in this policy for the listed high-risk medications.

Definitions

High Risk Medications (HRM) — definition

DefinitionHigh Risk Medications (HRM): Medications identified by the American Geriatrics Society Beers Criteria as potentially inappropriate in older adults and that may require avoidance, dose reduction, or careful monitoring.

Clinical implicationUse of an HRM should prompt prescriber acknowledgement that benefits outweigh risks for patients 70 years and older.

Policy purposePrior authorization is required for listed HRMs when prescribed to patients aged 70+ to ensure appropriate use per AGS Beers Criteria.

Background

This policy implements prior authorization for medications identified by the American Geriatrics Society (Beers Criteria) as potentially inappropriate in older adults. It requires prior authorization when such medications are prescribed to older patients and that the prescriber acknowledge the benefit-risk assessment, consider dose reduction, avoidance, or careful monitoring as indicated by the AGS guidance.