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pdfMEDICAID MANAGED CARE ORGANIZATION
DRUG UTILIZATION REVIEW ANNUAL REPORT
FEDERAL FISCAL YEAR ____
42 CFR 438.3(s)(4) and (5) require that each Medicaid managed care organization (MCO) must
operate a drug utilization review (DUR) program that complies with the requirements described
in Section 1927 (g) of the Social Security Act (the Act) and submit an annual report on the
operation of its DUR program activities. Such reports are to include: descriptions of the nature
and scope of the prospective and retrospective DUR programs; a summary of the interventions
used in retrospective DUR and an assessment of the education program; a description of DUR
Board activities; and an assessment of the DUR program’s impact on quality of care.
This report covers the period October 1, ____ to September 30, ____. Answering the attached
questions and returning the requested materials as attachments to the report will constitute
compliance with the above-mentioned statutory and regulatory requirements.
If you have any questions regarding the DUR Annual Report, please contact your state’s
Medicaid Pharmacy Program.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid O.M.B. control number. The valid O.M.B. control number for this information
collection is 0938-0659. The time required to complete this information collection is estimated to average __hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: Paperwork
Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
MEDICAID MANAGED CARE ORGANIZATION
DRUG UTILIZATION REVIEW ANNUAL REPORT
FEDERAL FISCAL YEAR ____
DEMOGRAPHIC INFORMATION
MCO Name:
Medicaid MCO Information
Identify your MCO person responsible for DUR Annual Report Preparation.
First Name:
Last Name:
Email Address:
Area Code/Phone Number:
On average, how many Medicaid beneficiaries are enrolled monthly in your MCO for
this Federal Fiscal Year?
beneficiaries
PROSPECTIVE DUR (ProDUR)
Indicate the type of your pharmacy point of service (POS) vendor and identify it by
name.
State-operated
Contractor, please identify by name.
Other organization, please identify by name.
Identify prospective DUR criteria source.
First Data Bank
Medi-Span
Other, please specify. Who reviews your new prospective-DUR criteria?
MCO’s DUR Board
FFS agency DUR Board
Other, please explain.
Are new ProDUR criteria approved by the DUR Board?
Yes
No, please explain.
When the pharmacist receives a level-one ProDUR alert message that requires a
pharmacist’s review, does your system allow the pharmacist to override the alert
using the “NCPDP drug use evaluation codes” (reason for service, professional
service and resolution)?
Yes
No
Partial, please explain.
Do you receive and review follow-up periodic reports providing individual pharmacy
provider override activity in summary and/or in detail?
Yes
No, please explain.
If the answer to question 6 is “No,” skip to question 7 on page 7.
If the answer to question 6 is “Yes,” please continue below.
How often do you receive reports?
Monthly
Quarterly
Annually
Other, please explain.
Do you follow up with those providers who routinely override with
interventions?
Yes
No, please explain.
If the answer to question 6b is “No,” skip to question 7 on page 7.
If the answer to question 6b is “Yes,” please continue below.
By what method do you follow up?
Contact Pharmacy
Refer to Program Integrity for Review
Other, please explain.
Early Refill
At what percent threshold do you set your system to edit?
Non-controlled drugs:
%
Schedule II controlled drugs:
%
Schedule III through V controlled drugs:
%
For non-controlled drugs
When an early refill message occurs, does your MCO require prior
authorization?
Yes
No
If the answer to question 7b is “Yes,” who obtains authorization?
Pharmacist
Prescriber
Both
If the answer to question 7b is “No,” can the pharmacist override at the point
of service?
Yes
No
For controlled drugs
When an early refill message occurs, does your MCO require prior
authorization?
Yes
No
If the answer to question 7c is “Yes,” who obtains authorization?
Pharmacist
Prescriber
Both
If the answer to question 7c is “No,” can the pharmacist override at the point
of service?
Yes
No
When the pharmacist receives an early refill DUR alert message that requires the
pharmacist’s review, does your MCO’s policy allow the pharmacist to override for
situations such as:
Lost/stolen Rx
Vacation
Other, please explain.
Does your system have an accumulation edit to prevent patients from continuously
filling prescriptions early?
Yes
No
If “Yes,” please explain your edits.
If “No,” do you plan to implement this edit?
Yes
No
Does the MCO have any policy prohibiting the auto-refill process that occurs at the
POS (i.e. must obtain beneficiary’s consent prior to enrolling in the auto-refill
program)?
Yes
No
Does your MCO have any policy that provides for the synchronization of prescription
refills (i.e. if the patient wants and pharmacy provider permits the patient to obtain
non-controlled chronic medication refills at the same time, your MCO would allow
this to occur to prevent the beneficiary from making multiple trips to the pharmacy
within the same month)?
Yes
No
For drugs not on your MCO’s formulary, does your MCO have a documented process
(i.e. prior authorization) in place, so that the Medicaid beneficiary or the Medicaid
beneficiary’s prescriber may access any covered outpatient drug when medically
necessary?
Yes
No
If “Yes,” what is the preauthorization process?
If “No,” please explain why there is not a process for the beneficiary to access a
covered outpatient drug when it is medically necessary.
Please list the requested data in each category in Table 1 – Top Drug Claims Data
Reviewed by the DUR Board below.
Table 1: Top Drug Claims Data Reviewed by the DUR Board
COLUMN 1
COLUMN 2
COLUMN 3
COLUMN 4
COLUMN 5
COLUMN 6
COLUMN 7
TOP 10
PRIOR
AUTHORIZAT
ION (PA)
REQUESTS BY
DRUG NAME
TOP 10
PRIOR
AUTHORIZAT
ION (PA)
REQUESTS BY
DRUG CLASS
TOP 5 CLAIM
DENIAL
REASONS
OTHER THAN
ELIGIBILITY
TOP 10 DRUG
NAMES BY
AMOUNT
PAID
% OF TOTAL
SPENT FOR
DRUGS BY
AMOUNT
PAID
TOP 10 DRUG
NAMES BY
CLAIM
COUNT
DRUGS BY
CLAIM
COUNT % OF
TOTAL
CLAIMS
(I.E. QUANTITY
LIMITS, EARLY
REFILL, PA,
THERAPEUTIC
DUPLICATIONS,
AGE EDITS)
FROM DATA IN
COLUMN 4,
DETERMINE THE
% OF TOTAL
DRUG SPEND.
FROM DATA IN
COLUMN 6,
DETERMINE THE
% OF TOTAL
CLAIMS.
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
RETROSPECTIVE DUR (RetroDUR)
Does your MCO utilize the same DUR Board as the state Fee-For-Service (FFS)
agency or does your MCO have its own DUR Board?
Same DUR Board as FFS agency
MCO has its own DUR Board
Other, please explain.
Identify the entity, by name and type, that performed your RetroDUR activities
during the time period covered by this report (company, academic institution, other
organization, or indicate if your MCO executed its own RetroDUR activities).
Who reviews and approves the RetroDUR criteria?
State DUR Board
MCO DUR Board
Other, please explain.
Has your MCO included Attachment 1 – Retrospective DUR Educational
Outreach Summary, a year end summary of the Top 10 problem types for which
educational interventions were taken?
Yes
No
See attachment naming instructions.
DUR BOARD ACTIVITY
Has your MCO included a brief summary of DUR Board activities during the time
period covered by this report as Attachment 2 - Summary of DUR Board
Activities?
Yes
No
Attachment 2 – Summary of DUR Board Activities
This summary should be a brief descriptive report on DUR Board activities during the
fiscal year reported. This summary should:
•
Indicate the number of DUR Board meetings held.
•
List additions/deletions to DUR Board approved criteria
For prospective DUR, list problem type/drug combinations added or deleted.
For retrospective DUR, list therapeutic categories added or deleted
•
Describe Board policies that establish whether and how results of prospective
DUR screening are used to adjust retrospective DUR screens. Also, describe
policies that establish whether and how results of retrospective DUR screening
are used to adjust prospective DUR screens.
•
Describe DUR Board involvement in the DUR education program (i.e.
newsletters, continuing education, etc.) Also, describe policies adopted to
determine mix of patient or provider specific intervention types (i.e. letters, faceto-face visits, increased monitoring).
See attachment naming instructions.
Does your MCO have a Medication Therapy Management Program?
Yes
No
If the answer to question 2 is “Yes,” please continue with questions a) and b) below.
Have you performed an analysis of the program’s effectiveness?
Yes, please provide a brief summary of your findings.
No
Is your DUR Board involved with this program?
Yes
No
If the answer to question 2 is “No,” are you planning to develop and implement a
program?
Yes
No
PHYSICIAN ADMINISTERED DRUGS
The Deficit Reduction Act required collection of NDC numbers for covered outpatient
physician administered drugs. These drugs are paid through the physician and hospital
programs. Has your pharmacy system been designed to incorporate this data into your
DUR criteria for:
ProDUR?
Yes
No
If “No,” do you have a plan to include this information in your DUR criteria in the
future?
Yes
No
RetroDUR?
Yes
No
If “No,” do you have a plan to include this information in your DUR criteria in the
future?
Yes
No
GENERIC POLICY AND UTILIZATION DATA
Has your MCO included a brief description of policies that may affect generic
utilization percentage as Attachment 3 – Generic Drug Substitution Policies?
Yes
No
See attachment naming instructions.
In addition to the requirement that the prescriber write in his own handwriting "Brand
Medically Necessary" for a brand name drug to be dispensed in lieu of the generic
equivalent, does your MCO have a more restrictive requirement?
Yes
No
If “Yes,” check all that apply:
Require that a MedWatch Form be submitted
Require the medical reason(s) for override accompany the prescription
Prior authorization is required
Prescriber must indicate “Brand Medically Necessary” on the prescription
Other, please explain.
Complete Table 2 – Generic Drug Utilization Data using the following Computation
Instructions.
Computation Instructions
Key
Single Source (S) – Drugs having an FDA New Drug Application (NDA), and
there are no generic alternatives available on the market.
Non-Innovator Multiple-Source (N) – Drugs that have an FDA Abbreviated
New Drug Application (ANDA), and generic alternatives exist on the market
Innovator Multiple-Source (I) – Drugs which have an NDA and no longer have
patent exclusivity.
Generic Utilization Percentage
To determine the generic utilization percentage of all covered outpatient drugs paid
during this reporting period, use the following formula
N ÷ (S + N + I) × 100 = Generic Utilization Percentage
Table 2: Generic Drug Utilization Data
Total Number of
Claims
Single Source (S)
Drugs
Non-Innovator (N)
Drugs
Innovator MultiSource (I) Drugs
CMS has developed an extract file from the Medicaid Drug Rebate Program Drug
Product Data File identifying each NDC along with sourcing status of each drug: S,
N, or I. This file will be made available from CMS to facilitate consistent reporting
across States with this data request.
Indicate the generic utilization percentage for all covered outpatient drugs paid during
this reporting period, using the computation instructions in Table 2 – Generic
Utilization Data.
Number of Generic Claims:
__________________
Total Number of Claims:
__________________
Generic Utilization Percentage: __________________
FRAUD, WASTE, AND ABUSE DETECTION
A.
LOCK-IN or PATIENT REVIEW AND RESTRICTION PROGRAMS
1. Do you have a documented process in place that identifies potential fraud or abuse of
controlled drugs by beneficiaries?
Yes
No
If “Yes,” what actions does this process initiate? Check all that apply:
Deny claims and require prior authorization
Refer to Lock-In Program
Refer to Program Integrity Unit
Other (i.e. SURS, Office of Inspector General), please explain.
2. Do you have a Lock-In program for beneficiaries with potential misuse or abuse of
controlled substances?
Yes
No
If the answer to question 2 is “No,” skip to question 3 on page 21.
If the answer to question 2 is “Yes,” please continue with questions a), b), c) and d)
below.
What criteria does your MCO use to identify candidates for Lock-In? Check
all that apply:
Number of controlled substances (CS)
Different prescribers of CS
Multiple pharmacies
Number days’ supply of CS
Exclusivity of short acting opioids
Multiple ER visits
PDMP data
Same FFS state criteria is applied
Other, please explain.
Do you have the capability to restrict the beneficiary to:
i) prescriber only
Yes
No
ii) pharmacy only
Yes
No
iii) prescriber and pharmacy only
Yes
No
What is the usual Lock-In time period?
12 months
18 months
24 months
Other, please explain.
On average, what percentage of your Medicaid MCO population is in Lock-In
status annually?
%
3. Do you have a documented process in place that identifies possible fraud or abuse of
controlled drugs by prescribers?
Yes
No
If “Yes,” what actions does this process initiate? Check all that apply:
Deny claims written by this prescriber
Refer to Program Integrity Unit
Refer to the appropriate Medical Board
Other, please explain.
4. Do you have a documented process in place that identifies potential fraud or abuse of
controlled drugs by pharmacy providers?
Yes
No
If “Yes,” what actions does this process initiate? Check all that apply:
Deny claims
Refer to Program Integrity Unit
Refer to Board of Pharmacy
Other, please explain.
5. Do you have a documented process in place that identifies and/or prevents potential
fraud or abuse of non-controlled drugs by beneficiaries?
B.
Yes, please explain your program for fraud, waste or abuse of non-controlled
substances.
No
PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
1. Do you require prescribers (in your provider agreement with your MCO) to access the
PDMP patient history before prescribing controlled substances?
Yes, please explain how the MCO applies this information to control fraud and
abuse.
No
No, the state does not have a PDMP
2. Does your MCO have the ability to query the state’s PDMP database?
Yes
No
If “Yes,” are there barriers that hinder your MCO from fully accessing the PDMP that
prevent the program from being utilized the way it was intended to be to curb abuse?
Yes, please explain the barriers that exist.
No
3. Does your MCO have access to border states’ PDMP information?
C.
Yes
No
PAIN MANAGEMENT CONTROLS
1. Does your MCO obtain the DEA Active Controlled Substance Registrant’s File in
order to identify prescribers not authorized to prescribe controlled drugs?
Yes
No
If the answer to question 1 is “No,” skip to question 2 below.
If the answer to question 1 is “Yes,” please continue.
Do you apply this DEA file to your ProDUR POS edits to prevent unauthorized
prescribing?
Yes
No
If “Yes,” please explain how information is applied.
If “No,” do you plan to obtain the DEA Active Controlled Substance
Registrant’s file and apply it to your POS edits?
Yes
No
2. Do you apply this DEA file to your RetroDUR reviews?
Yes, please explain how it is applied.
No
3. Do you have a measure (i.e. prior authorization, quantity limits) in place to either
monitor or manage the prescribing of methadone for pain management?
D.
Yes
No, please explain why you do not have a measure in place to either manage or
monitor the prescribing of methadone for pain management.
OPIOIDS
1. Do you currently have a POS edit in place to limit the quantity dispensed of an initial
opioid prescription?
Yes for all opioids
Yes for some opioids
No for all opioids
If the answer to question 1 is “No,” skip to question 2 on page 26.
If the answer to question 1 is “Yes for all opioids” or “Yes for some opioids,” please
continue with questions a), b) and c) below.
Is there more than one quantity limit for the various opioids?
Yes, please explain.
No
What is your maximum number of days allowed for an initial opioid
prescription?
days
Does the above initial day limit apply to all opioid prescriptions?
Yes
No, please explain.
2. For subsequent prescriptions, do you have POS edits in place to limit the quantity
dispensed of short-acting opioids?
Yes
No
If “Yes,” what is your maximum days supply per prescription limitation?
30 day supply
90 day supply
Other, please explain.
3. Do you currently have POS edits in place to limit the quantity dispensed of longacting opioids?
Yes
No
If “Yes,” what is your maximum days supply per prescription limitation?
30 day supply
90 day supply
Other, please explain.
4. Do you have measures other than restricted quantities and days supply in place to
either monitor or manage the prescribing of opioids?
Yes
No
If “Yes,” please check all that apply:
Pharmacist override
Deny claim and require PA
Intervention letters
Morphine equivalent daily dose (MEDD) program
Step therapy or clinical criteria
Requirement that patient has a pain management contract or PatientProvider agreement
Requirement that prescriber has an opioid treatment plan for patients
Require documentation of urine drug screening results
Other, please explain what additional opioid prescribing controls are in
place.
If “No,” please explain what you do in lieu of the above or why you do not have
measures in place to either manage or monitor the prescribing of opioids.
5. Do you currently have edits in place to monitor opioids and benzodiazepines being
used concurrently?
Yes, please explain.
No
6. Do you perform any RetroDUR activity and/or provider education in regard to
beneficiaries with a diagnosis or history of opioid use disorder (OUD) or opioid
poisoning diagnosis?
Yes
No
If the answer to question 6 is “Yes,” please indicate how often:
Monthly
Quarterly
Semi-Annually
Annually
Other, please explain.
If the answer to question 6 is “No,” do you plan on implementing a RetroDUR
activity and/or provider education in regard to beneficiaries with a diagnosis or
history of OUD or opioid poisoning in the future?
Yes
No
7. Does your state Medicaid agency develop and provide prescribers with pain
management or opioid prescribing guidelines?
Yes
No
For either “Yes” or “No,” please check all that apply:
Your MCO refers prescribers to the CDC’s Guideline for Prescribing
Opioids for Chronic Pain. Please identify the "referred" guidelines.
Other guidelines, please identify.
No guidelines are offered.
8. Do you have a drug utilization management strategy that supports abuse deterrent
opioid use to prevent opioid misuse and abuse (i.e. presence of an abuse deterrent
opioid with preferred status on your preferred drug list)?
Yes, please explain.
No
E.
MORPHINE EQUIVALENT DAILY DOSE (MEDD)
1. Have you set recommended maximum morphine equivalent daily dose measures?
Yes
No
If the answer to question 1 is “Yes,” please continue with questions a) and b) below.
What is your maximum morphine equivalent daily dose limit in milligrams?
mg per day
Please explain (i.e. are you in the process of tapering patients to achieve this
limit?).
If the answer to question 1 is “No,” please explain the measure or program you
utilize.
2. Do you provide information to your prescribers on how to calculate the morphine
equivalent daily dosage or do you provide a calculator developed elsewhere?
Yes
No
If the answer to question 2 is “No,” skip to question 3 on page 32.
If the answer to question 2 is “Yes,” please continue with questions a) and b) below.
Please name the developer of the calculator.
How is the information disseminated? Check all that apply:
Website
Provider notice
Educational seminar
Other, please explain.
3. Do you have an edit in your POS system that alerts the pharmacy provider that the
morphine equivalent daily dose prescribed has been exceeded?
Yes
No
If “Yes,” do you require prior authorization if the MEDD limit is exceeded?
F.
Yes
No
BUPRENORPHINE, NALOXONE, BUPRENORPHINE/NALOXONE
COMBINATIONS and METHADONE for OPIOID USE DISORDER (OUD)
1. Does your MCO set total mg per day limits on the use of buprenorphine and
buprenorphine/naloxone combination drugs?
Yes
No
If “Yes,” please specify the total mg/day:
12 mg
16 mg
24 mg
Other, please explain.
2. What are your limitations on the allowable length of this treatment?
6 months
12 months
No limit
Other, please explain.
3. Do you require that the maximum mg per day allowable be reduced after a set period
of time?
Yes
No
If “Yes,” please continue with questions a) and b) below.
What is your reduced (maintenance) dosage?
8 mg
12 mg
16 mg
Other, please explain.
What are your limitations on the allowable length of the reduced dosage
treatment?
6 months
12 months
No limit
Other, please explain.
4. Do you have at least one buprenorphine/naloxone combination product available
without prior authorization?
Yes
No
5. Do you currently have edits in place to monitor opioids being used concurrently with
any buprenorphine drug?
Yes
No
Other, please explain.
If “Yes,” can the POS pharmacist override the edit?
Yes
No
6. Do you have at least one naloxone opioid overdose product available without prior
authorization?
Yes
No
7. Does your MCO allow pharmacists to dispense naloxone prescribed independently, or
by collaborative practice agreements, or standing orders, or other predetermined
protocols?
Yes
No
8. Does your MCO cover methadone for OUD (i.e. Methadone Treatment Center)?
G.
Yes
No
ANTIPSYCHOTICS /STIMULANTS
ANTIPSYCHOTICS
1. Do you currently have restrictions in place to limit the quantity of antipsychotics?
Yes
No, please explain.
2. Do you have a documented program in place to either manage or monitor the
appropriate use of antipsychotic drugs in children?
Yes
No
If “Yes,” please continue with questions a), b) and c) below.
Do you either manage or monitor:
Only children in foster care
All children
Other, please explain.
Do you have edits in place to monitor (check all that apply):
Child’s Age
Dosage
Polypharmacy
Other, please explain.
Please briefly explain the specifics of your antipsychotic monitoring
program(s).
If you do not have an antipsychotic monitoring program in place, do you plan on
implementing a program in the future?
Yes
No, please explain why you will not be implementing a program to monitor
the appropriate use of antipsychotic drugs in children.
STIMULANTS
3. Do you currently have restrictions in place to limit the quantity of stimulants?
Yes
No
4. Do you have a documented program in place to either manage or monitor the
appropriate use of stimulant drugs in children?
Yes
No
If the answer to question 4 is “Yes,” please continue with questions a), b) and c) below.
Do you either manage or monitor:
Only children in foster care
All children
Other, please explain.
Do you have edits in place to monitor (check all that apply):
Child’s Age
Dosage
Polypharmacy
Please briefly explain the specifics of your documented stimulant monitoring
program(s).
If the answer to question 4 is “No,” that is you do not have a documented stimulant
monitoring program in place, do you plan on implementing a program in the future?
Yes
No, please explain why you will not be implementing a program to monitor
the appropriate use of stimulant drugs in children.
INNOVATIVE PRACTICES
Attachment 4 – Innovative Practices
Have you developed any innovative practices during the past year (i.e. Substance Use
Disorder, Hepatitis C, Cystic Fibrosis, MEDD, Value Based Purchasing)? Please describe
in detailed narrative form any innovative practices that you believe have improved the
administration of your DUR program, the appropriateness of prescription drug use and/or
have helped to control costs (i.e. disease management, academic detailing, automated
prior authorizations, continuing education programs).
Please include Attachment 4 described above when submitting this survey. (See naming
instructions.)
E-PRESCRIBING
Does your pharmacy system or vendor have a portal to electronically provide patient
drug history data and pharmacy coverage limitations to a prescriber prior to
prescribing upon inquiry?
Yes
No
If the answer to question 1 is “Yes,” do you have a methodology to evaluate the
effectiveness of providing drug information and medication history prior to
prescribing?
Yes, please explain the evaluation methodology in Attachment 5 –
E-Prescribing Activity Summary. Describe all development and
implementation plans/accomplishments in the area of e-prescribing. Include
any evaluation of the effectiveness of this technology (i.e., number of
prescribers e-prescribing, percent e-prescriptions to total prescriptions,
relative cost savings).
Please include Attachment 5 described above when submitting this survey.
(See naming instructions.)
No
If the answer to question 1 is “No,” are you planning to develop this capability?
Yes
No
Does your system use the NCPDP Origin Code that indicates the prescription source?
Yes
No
EXECUTIVE SUMMARY
Attachment 6 – Executive Summary
Please include Attachment 6 when submitting this survey. (See naming instructions.)
APPENDIX
INSTRUCTIONS: Nomenclature Format for Attachments
MCO: Please use this standardized format for naming attachments:
ATT#-FFY-State Abbrev-MCO name-Abbreviated Report name (NO SPACES!)
Example for Arizona: (each MCO should insert its 2 letter state code and its first name)
Attachments:
ATT1-20_ _-AZ-Amerigroup-REOS
(RetroDUR Educational Outreach Summary)
ATT2-20_ _-AZ-Amerigroup-SDBA
(Summary of DUR Board Activities)
ATT3-20_ _-AZ-Amerigroup-GDSP
(Generic Drug Substitution Policies)
ATT4-20_ _-AZ-Amerigroup-IPN
(Innovative Practices Narrative)
ATT5-20_ _-AZ-Amerigroup-EAS
(E-Prescribing Activity Summary)
ATT6-20_ _-AZ-Amerigroup-ES
(Executive Summary)
| File Type | application/pdf |
| File Title | Medicaid DUR Annual Report 2018 - MCO |
| Author | Division of Pharmacy |
| File Modified | 2018-07-20 |
| File Created | 2018-07-19 |