MedicaidPrior AuthMedium impact
20-419 Avoid Compliance Issues: New Drug Utilization Review Requirements Target Opioids
Health Net·CA · Family Medicine, Internal Medicine, General Practice +5 more·Prior Authorization
Effective date
Oct 1, 2019
We identified it
Jun 20, 2026
Summary
Health Net CalViva Health has implemented new Drug Utilization Review (DUR) requirements for opioid prescriptions in Fresno, Kings and Madera counties, including mandatory prior authorization for MME doses over 500/day, 30-day acute medication limits, and concurrent drug monitoring. Providers must also monitor antipsychotic use in children and report fraud/abuse findings.
Action Required
Immediately: Billing team must ensure prior authorization is obtained for opioid prescriptions exceeding 500 MME/daily, acute medications over 30-day supply, chronic medications over 90-day supply, and off-label antipsychotic use in children. Update billing system to flag these scenarios and alert providers. Claims without proper prior authorization will be denied for Medi-Cal members in Fresno, Kings and Madera counties.