MedicaidPrior AuthHigh impact
23-1489m Stay in Compliance With Drug Utilization Review Requirements That Target Opioids
Health Net·CA · Pain Management, Family Medicine, Internal Medicine +3 more·Prior Authorization
Effective date
Sep 25, 2023
We identified it
Jun 20, 2026
Summary
California health plans must implement enhanced drug utilization review (DUR) programs targeting opioid prescriptions, including safety edits for early refills, daily morphine limits, and concurrent drug monitoring. Providers must comply with new policies and procedures that include prior authorization requirements for opioids exceeding specific thresholds and reporting of fraud, waste and abuse.
Action Required
By December 24, 2023 (90 days from APL release): Review and update policies and procedures to comply with DUR requirements including opioid safety edits, MME limits of 500 daily without prior auth, early refill restrictions (no refills before 75% depletion), and concurrent medication monitoring. Billing team must ensure prior authorization processes are in place for opioids exceeding safety thresholds. Implement fraud reporting procedures using hotline 866-685-8664. Failure to comply may result in claim denials and regulatory violations.