CurrentNeighborhood Health Plan of Rhode IslandPolicy 698-B

High Risk Medications (HRM) Long List - Prior Authorization with Age (Policy 698-B)

Defines prior authorization (PA) requirements that apply only to patients 70 years of age or older for a long list of high-risk medications (HRMs) identified largely from the AGS Beers Criteria. Lists specific drug names/classes subject to PA, the required prescriber acknowledgement, and authorization duration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHigh Risk Medications (HRM) Long List - Prior Authorization with Age (Policy 698-B)

Policy CodePolicy 698-B

Change TypeClarified / Revised

Effective Date

Next Review Date

Key ActionPrior authorization applies only to patients 70 years of age or older for the listed high-risk medications; prescriber must acknowledge that benefits outweigh risks.

SourceLink

POLICY UPDATE CHANGES

Prior Authorization applies only to patients 70 years of age or older.

Lists of specific high-risk medications (long list) associated with the PA policy were included.

>=70Age threshold (years)

12Duration of approval

MultipleDrug classes listed

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Policy 698-B: Prior authorization for High Risk Medications (HRM) by age. Defines prior authorization (PA) requirements that apply only to patients 70 years of age or older for a long list of high-risk medications identified largely from the American Geriatrics Society Beers Criteria. Lists specific drug names/classes subject to PA, requires prescriber acknowledgement that benefits outweigh risks, and sets authorization duration at 12 months. Last review: 2024-02-01.

Prior Authorization Eligibility

Authorization may be granted for the requested drug when the following criteria is met:

Age threshold: Patient is 70 years of age or older>= 70 years
Prior Authorization applies only to patients 70 years of age or older.
AGS identification: The American Geriatrics Society identifies the use of this medication as potentially inappropriate in older adults (i.e., best avoided, prescribed at reduced dosage, or used with caution or careful monitoring)
Defines High Risk Medications (HRM) per AGS Beers Criteria.
Prescriber acknowledgement: The prescriber acknowledges that the benefit of therapy with this prescribed medication outweighs the potential risks for this patient
Prescriber must document acknowledgement as condition of authorization.

Drugs Subject to Prior Authorization

Drugs subject to PA (listed by therapeutic class / examples)mixedCovered

	ANTIARRHYTHMIC: disopyramide; disopyramide extended release
	ANTIDEPRESSANT: amitriptyline; clomipramine; doxepin (capsules, tablets; solution applies to >6 mg daily); imipramine hydrochloride; imipramine pamoate
	ANTIEMETIC: scopolamine patch
	ANTIHISTAMINE: carbinoxamine maleate; clemastine fumarate; cyproheptadine hydrochloride; dexchlorpheniramine maleate; diphenhydramine (oral); hydroxyzine hydrochloride; hydroxyzine pamoate; promethazine hydrochloride; promethazine/phenylephrine
	ANTI-INFECTIVE: nitrofurantoin
	ANTINEOPLASTIC: megestrol acetate (tablet and suspension)
	ANTIPARKINSON: benztropine mesylate (oral dosage form only); trihexyphenidyl hydrochloride
	ANTIPSYCHOTIC-ANTIDEPRESSANT COMBINATION: perphenazine-amitriptyline
	ANTISPASMODIC: methscopolamine
	BARBITURATE-ANALGESIC: butalbital combinations (butalbital-APAP, butalbital-APAP-caffeine, butalbital-ASA-caffeine, butalbital-APAP-caffeine w/ codeine)

1–10 of 19

1/2

Provider Requirements & Operational Rules

Prior Authorization

Prior Authorization required for HRMs in patients >=70

Prior Authorization applies only to patients 70 years of age or older for the listed high-risk medications. The prescriber must acknowledge that the benefit of therapy with this prescribed medication outweighs the potential risks for this patient when seeking authorization.

Multiple therapeutic classes listed (e.g., antiarrhythmics, antidepressants, antihistamines, nitrofurantoin, digoxin, non-benzodiazepine hypnotics, skeletal muscle relaxants)

Documentation Required

Prescriber acknowledgement required

The prescriber must acknowledge that the benefit of therapy with this prescribed medication outweighs the potential risks for this patient as identified by the American Geriatrics Society criteria.

Billing Rule

Duration of approval

Duration of approval for policy 698-B: 12 months.

Clinical Evidence & Definitions

This prior authorization (PA) policy implements age-based management of medications identified as potentially inappropriate or high-risk in older adults to ensure prescriber acknowledgement that benefits outweigh risks before dispensing. It references the American Geriatrics Society Beers Criteria and related quality measures and literature to guide determinations. The intent is to require prescribers to confirm that therapy with a listed medication is appropriate for the patient despite AGS-identified risks.

Definition: High Risk Medications (HRM) — Medications identified by the American Geriatrics Society as potentially inappropriate in older adults (use to be avoided, dose-reduced, or used with caution/monitoring).

Evidence and references include the American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2019) and related literature cited in the policy references, including publications on inappropriate medications and hospitalization risk, quality measure user guides, alternative medication guidance for high-risk drugs in the elderly, Pharmacy Quality Alliance measure manuals, and drug information resources (Lexicomp, Micromedex).

Revision History

2024-02-01Last reviewLatest

Last review

Policy clarification

Age-based PA restriction explicitly stated in header and criteria: Prior Authorization applies only to patients 70 years of age or older.

Material change

Lists of specific high-risk medications (long list) associated with the PA policy were included: enumerated therapeutic classes and specific drug examples including nitrofurantoin, digoxin (applies to >0.125 mg daily), non-benzodiazepine sedative-hypnotics (eszopiclone, zaleplon, zolpidem formulations), many antidepressants (including doxepin solution >6 mg/day), estrogens, glyburide, skeletal muscle relaxants, barbiturate-analgesic combinations, and others.