MedicaidAdministrativeMedium impact
24-643m Stay in Compliance With Drug Utilization Review Requirements
Health Net·CA · Psychiatry, Family Medicine, Internal Medicine +4 more·Prior Authorization
We identified it
Jun 20, 2026
Summary
California Medicaid managed care providers must implement enhanced drug utilization review (DUR) programs to monitor concurrent prescribing of opioids with benzodiazepines/antipsychotics and antipsychotic medications for children under 18. Providers must also establish processes to identify and report fraud, waste, and abuse related to controlled substances.
Action Required
Immediately: Establish processes to monitor and flag concurrent prescribing of opioids with benzodiazepines or antipsychotics during claims review. Implement monitoring system for all psychiatric medications (antipsychotics, mood stabilizers, antidepressants) prescribed to children under 18 and foster children. Create documentation procedures to identify potential fraud, waste, and abuse of controlled substances. Train staff on reporting suspected violations to compliance hotline 866-685-8664. Exempt hospice, palliative care, cancer treatment, long-term care facility residents, and substance use disorder treatment patients from monitoring requirements.