CurrentNeighborhood Health Plan of Rhode IslandPolicy 698-B

High Risk Medications (HRM) Prior Authorization — Age-Based

Defines prior authorization requirements for a long list of high-risk medications when prescribed to patients aged 70 years or older; applies to medication prescribing and pharmacy benefit administration for covered members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHigh Risk Medications (HRM) Prior Authorization — Age-Based

Policy CodePolicy 698-B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed high‑risk medications when prescribed to patients aged 70 years or older and document the prescriber's risk/benefit acknowledgement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

70+age threshold requiring prior authorization

12 monthsduration of approval (DOA)

multiplecovered high-risk medication classes listed

Beersclinical reference

Coverage Criteria

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Initial Prior Authorization (Age-based)

Authorization may be granted when ALL of the following are met

Age requirement: Patient is 70 years of age or older.>=70 years

PA applies only to patients 70+.

Medication listed as HRM: Requested drug is included in the policy's High Risk Medications list.listed drug

See HRM list in policy (e.g., chunk 0).

Prescriber acknowledgement: Prescriber acknowledges that the benefit of therapy with the prescribed medication outweighs the potential risks for this patient, consistent with American Geriatrics Society guidance.acknowledgement documented

Required per coverage criteria (chunk 5).

No explicit exclusions are listed in the policy text. The document does not identify any drugs, indications, patient groups, or situations that are exempt from the age-based prior authorization requirement; therefore, implementers should treat the policy as applying to all listed high-risk medications prescribed to members meeting the age criteria unless a separate policy or directive states otherwise.

The policy references the American Geriatrics Society (AGS) Beers Criteria as the clinical guidance for identifying medications that are considered potentially inappropriate in older adults. Prescribers must consider AGS guidance when determining whether the benefit of therapy outweighs risks for patients in the affected age group.

Medication / Coding List

High Risk Medication (HRM) - Covered Drug List (by name/class)mixedCovered

disopyramide	disopyramide; disopyramide extended release
digoxin >0.125 mg/day	digoxin tablets, oral solution — applies to > 0.125 mg daily
amitriptyline	amitriptyline (tricyclic antidepressant)
clomipramine	clomipramine
doxepin >6 mg/day	doxepin (capsules, tablets, solution) — applies to > 6 mg daily
imipramine hydrochloride	imipramine hydrochloride; imipramine pamoate
scopolamine patch	scopolamine (patch)
carbinoxamine maleate	carbinoxamine maleate
clemastine fumarate	clemastine fumarate
cyproheptadine hydrochloride	cyproheptadine hydrochloride

1–10 of 29

1/3

Medication / Coding List

Digoxin daily dose threshold> 0.125 mg daily

Medication / Coding List

Doxepin applicability threshold> 6 mg daily

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required for Patients ≥ 70

Prior Authorization is required for requests for any listed High-Risk Medication when the patient is 70 years of age or older. Requests for patients under age 70 are not subject to this PA requirement per this policy.

Applies to all medications on the High Risk Medications (HRM) long list

Step Therapy

Type: Initial Prior Authorization with Age

Type: Initial Prior Authorization with Age. This policy specifies an age-based initial prior authorization; no additional step-therapy requirements are specified in this section.

Documentation Required

Prescriber Risk-Benefit Acknowledgement Required

For authorization to be considered, the prescriber must acknowledge that the medication is identified by the American Geriatrics Society as potentially inappropriate or high-risk in older adults and that, after clinical consideration, the benefit of therapy for this specific patient outweighs the potential risks. Documentation of this risk-benefit acknowledgement should be included with the PA request.

Reference: American Geriatrics Society criteria for potentially inappropriate medications in older adults

Denial Risk

Denial Risk if PA Not Obtained for Patients ≥ 70

Requests for listed high-risk medications for patients aged 70 and older that do not have an approved prior authorization may be denied or treated as non-covered. Providers should obtain PA approval prior to dispensing to avoid claim denials.

Lack of prior authorization for patients ≥ 70 may result in denial or non-coverage

Initial Prior Authorization Criteria

Initial PA with Age

Initial prior authorization requirement

Age: Patient is 70 years or older.>=70

Prior Authorization applies only to patients 70 years of age and older (see chunk 0).

Drug listed as HRM: Requested medication is on the High Risk Medication (HRM) list contained in this policy.listed drug

HRM examples include agents listed in chunk 0; full list in policy document.

Prescriber attestation: Prescriber acknowledges that the benefit of therapy outweighs the risks for this patient, consistent with the American Geriatrics Society recommendations.attestation documented

Documentation required as part of PA (chunk 5).

Step	Requirement / Type	Details
1
Initial Prior Authorization with Age
Prior authorization required for patients 70 years of age or older; no additional step therapy requirements specified.

Definitions

Potentially Inappropriate Medication (older adults)

DefinitionMedications the American Geriatrics Society identifies as potentially inappropriate in older adults because they are best avoided, require reduced dosage, or need caution and careful monitoring.

Source guidanceBased on the American Geriatrics Society Beers Criteria (referenced in policy references).

Policy implicationUse of these medications in older adults requires prescriber acknowledgement that benefits outweigh risks for patients aged 70 and older.

Typical actionsMay be avoided, prescribed at reduced dosage, or used with heightened monitoring as indicated by AGS guidance.

Background

This policy targets medications identified by the American Geriatrics Society Beers Criteria as potentially inappropriate in older adults. These agents are considered best avoided, require dose reductions, or need enhanced monitoring because the risks may outweigh benefits in older patients. For members aged 70 years or older, the policy requires an initial prior authorization and a prescriber attestation that the expected benefit justifies use despite AGS concerns.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHigh Risk Medications (HRM) Prior Authorization — Age-Based

Policy CodePolicy 698-B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed high‑risk medications when prescribed to patients aged 70 years or older and document the prescriber's risk/benefit acknowledgement.

SourceLink

On This Page

OpenPayer

High Risk Medications (HRM) Prior Authorization — Age-Based

Coverage Criteria

Medication / Coding List

Provider Actions & Prior Authorization Requirements

Initial Prior Authorization Criteria

Step Therapy & Related Rules

Definitions

Background