MedicaidPrior AuthHigh impact
20-418 Avoid Compliance Issues: New Drug Utilization Review Requirements Target Opioids
Health Net·CA · Family Medicine, Internal Medicine, Pain Management +2 more·Prior Authorization
Effective date
Oct 1, 2019
We identified it
Jun 20, 2026
Summary
Health Net has implemented new Drug Utilization Review (DUR) requirements targeting opioid prescriptions for Medi-Cal members in specific California counties. The policy establishes safety edits including quantity limits, early refill restrictions, maximum daily morphine equivalent limits of 500 MME without prior authorization, and monitoring for concurrent use of opioids with benzodiazepines or antipsychotics.
Action Required
Immediately: Billing team must ensure opioid prescriptions comply with new DUR requirements: (1) Do not allow refills earlier than 75% of previous fill exhaustion, (2) Obtain prior authorization for opioid prescriptions exceeding 500 MME daily for chronic pain, (3) Limit acute opioid medications to 30-day supply and chronic to 90-day supply without prior auth, (4) Flag concurrent prescriptions of opioids with benzodiazepines or antipsychotics for review. Update billing system edits to enforce these limits. Claims not meeting these requirements may be denied.