CurrentNeighborhood Health Plan of Rhode IslandPolicy 698-B UDR 02-2024

High Risk Medications Hrm Long List Pa With Age Policy 698 B Udr 02 2024

Defines prior authorization (PA) requirements for a long list of high-risk medications for members aged 70 years and older; lists included drugs by therapeutic class, PA clinical criterion, and duration of approval. Applies to medications identified as potentially inappropriate in older adults per AGS/Beers criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHigh Risk Medications Hrm Long List Pa With Age Policy 698 B Udr 02 2024

Policy CodePolicy 698-B UDR 02-2024

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior Authorization is required for listed high-risk medications when the patient is 70 years of age or older; prescriber must acknowledge that benefits outweigh risks.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes identified (has_material_change=false).

70PA Age Threshold (years)

12 moDuration of Approval

~30+Listed Medications

Coverage Summary

Defines prior authorization (PA) requirements for a long list of High Risk Medications (HRM) Long List for members aged 70 years and older. The policy lists included drugs by therapeutic class (e.g., antiarrhythmic, antidepressant, antihistamine, cardiovascular, estrogens, non‑benzodiazepine sedative‑hypnotics, skeletal muscle relaxants, etc.) and specifies PA clinical criteria and duration of approval. Authorization may be granted when the prescriber acknowledges that the medication is identified by the American Geriatrics Society as potentially inappropriate in older adults and that the benefit of therapy outweighs the potential risks for the patient.

Initial Prior Authorization Criteria

Prior Authorization Criteria

Authorization may be granted when ALL of the following are met:

Age requirement: Patient is 70 years of age or older
Prior Authorization applies only to patients 70 years of age or older.
AGS Beers Criteria acknowledgement: 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/monitoring)
Prescriber must acknowledge that benefit of therapy outweighs potential risks for this patient.

Listed High-Risk Medications (by class)

Listed High Risk Medications (by class) - subject to PA with agemixedCovered

	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 forms only); trihexyphenidyl hydrochloride
	ANTIPSYCHOTIC-ANTIDEPRESSANT COMBINATION: perphenazine-amitriptyline
	ANTISPASMODIC: methscopolamine
	BARBITURATE-ANALGESIC: phenobarbital = butalbital-acetaminophen; butalbital-acetaminophen-caffeine; butalbital-aspirin-caffeine; butalbital-acetaminophen-caffeine with codeine

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Provider Actions / Prior Authorization Requirements

Prior Authorization

Age-based Prior Authorization (PA)

Prior Authorization is required for listed high-risk medications when the patient is 70 years of age or older; prescriber must acknowledge that benefits outweigh risks.

Applies when patient is 70 years of age or older.

Documentation Required

Prescriber risk-benefit acknowledgement

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

Billing Rule

Duration of Approval

When authorized under this policy (698-B), Duration of Approval (DOA) is 12 months.

Duration of Approval (DOA): 12 months

Clinical Evidence & References

Background: This policy implements an age‑based prior authorization consistent with the American Geriatrics Society Updated Beers Criteria for potentially inappropriate medication use in older adults. The policy’s primary clinical reference is the American Geriatrics Society Updated Beers Criteria (2019).

Evidence and supporting sources include Pharmacy Quality Alliance (PQA) measures and multiple literature sources addressing harms and quality measures for high‑risk medications in older adults (e.g., PQA measure manual, studies of potentially inappropriate medications and hospitalization risk, and measurement/user guides). Specific references cited by the policy include the AGS Beers Criteria (2019), PQA 2022 Measure Manual, and other literature and resources listed in the policy references.

Definitions & Background

High Risk Medications (HRM) Long List: A list of medications considered potentially inappropriate for older adults and subject to age‑based prior authorization under this policy.

This policy applies an age‑based prior authorization requiring PA for listed HRMs when the patient is 70 years of age or older and the prescriber acknowledges that the benefit of therapy outweighs the potential risks as identified by the American Geriatrics Society (e.g., best avoided, dose reduction, or use with caution/monitoring).