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pdfFFY 2020
FEE-FOR-SERVICE DRUG UTILIZATION REVIEW ANNUAL SURVEY
ABOUT THE SURVEY
Section 1927(g)(3)(D) of the Social Security Act (the Act) requires each state to submit an annual
report on the operation of its Medicaid Drug Utilization Review (DUR) program. 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 as well as any cost savings generated by the program.
Note: Covered Outpatient Drugs (COD) are referenced throughout this survey and refers to
participating labelers in the Medicaid Drug Rebate Program (MDRP).
This report covers the period October 1, 2019 to September 30, 2020 and is due for submission to
CMS Central Office by no later than July 1, 2021. Answering the attached questions and returning
the requested materials as attachments to the report will constitute compliance with the abovementioned statutory requirement.
If you have any questions regarding the DUR Annual Report, please contact CMS via email at:
[email protected].
PRA DISCLOSURE STATEMENT (CMS-R-153)
This mandatory information collection (section 4401 of the Omnibus Budget Reconciliation Act of 1990 and section
1927(g) of the Social Security Act) is necessary to establish patient profiles in pharmacies, identify problems in
prescribing and/or dispensing, determine each program’s ability to meet minimum standards required for Federal
financial participation, and ensure quality pharmaceutical care for Medicaid patients. State Medicaid agencies that
have prescription drug programs are required to perform prospective and retrospective DUR in order to identify
aberrations in prescribing, dispensing and/or patient behavior. Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid Office of
Management and Budget (OMB) control number. The control number for this information collection request is 09380659 (Expires: 11/30/2022). Public burden for all of the collection of information requirements under this control
number is estimated at 64 hours per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FFY 2020
I.
FEE-FOR-SERVICE DRUG UTILIZATION REVIEW ANNUAL SURVEY
DEMOGRAPHIC INFORMATION
State Abbreviation: _______
Medicaid Program Information
Identify State person responsible for DUR Annual Report Preparation.
First Name:
_____________________________________
Last Name:
_____________________________________
Email Address:
_____________________________________
Area Code/Phone Number:
_____________________________________
1. On a monthly average, how many of your state’s Medicaid beneficiaries are enrolled
in your state’s Medicaid Fee-for-Service (FFS) program that have a pharmacy
benefit?
_________Beneficiaries
2. On a monthly average, how many of your state’s Medicaid beneficiaries are enrolled
in managed care plan(s)?
_________ Beneficiaries
II.
PROSPECTIVE DUR (ProDUR)
1. Indicate the type of your pharmacy point of service (POS) vendor.
State-Operated
Contractor
Other
Vendor Name
Who process the state’s National Council for Prescription Drug Programs
(NCPDP) transactions?
POS vendor is the fiscal agent (FA)
POS vendor is a separate Pharmacy Benefits Manager (PBM)
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None
Identify your ProDUR table driven criteria source. This would be initial ratings such
as drug to drug interactions, dose limits based on age and pregnancy severity.
First Data Bank
Medi-Span
MICROMEDEX
Other, please specify ________________________________
When the pharmacist receives a 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
Varies by Alert Type
No
If “Yes” or “Varies by Alert Type, check all that apply.
Alerts can be overridden ahead of time
Alerts can be overridden with standard professional codes
Alerts need prior authorization (PA) to be overridden.
Other, please explain.
______________________________________________________
Do you receive periodic reports providing individual pharmacy provider DUR alert
override activity in summary and/or in detail?
Yes
How often do you receive reports?
Monthly
Quarterly
Annually
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Ad hoc (on request)
Other, please explain.
___________________________________________________________
If you receive reports, do you follow up with those providers who routinely
override with interventions?
Yes
By what method do you follow up?
Contact Pharmacy
Refer to Program Integrity for Review
Other, please explain.
___________________________________________________________
No
No, please explain.
_____________________________________________________________________
5. Early Refill:
a. At what percent threshold do you set your system to edit?
i.
Non-controlled drugs:
______%
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ii.
Schedule II controlled drugs:
______%
iii.
Schedule III through V controlled drugs:
______%
b. For non-controlled drugs:
When an early refill message occurs, do you require a PA?
Yes
No
Dependent on medication or situation
If “Yes” or “Dependent on medication or situation”, who obtains
authorization?
Pharmacist
Prescriber
Pharmacist or Prescriber
If “No”, can the pharmacist override at the POS?
Yes
No
c. For controlled drugs:
When an early refill message occurs, does your state require a PA?
Yes
No
If “Yes”, who obtains authorization?
Pharmacist
Prescriber
Pharmacist or Prescriber
If “No”, can the pharmacist override at the POS?
Yes
No
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6. When the pharmacist receives an early refill DUR alert message that requires the
pharmacist’s review, does your state’s policy allow the pharmacist to override for
situations such as:
a. Lost/stolen Rx:
Yes
No
Overrides are only allowed by a pharmacist through a PA
Vacation:
Yes
No
Overrides are only allowed by a pharmacist through a PA
Other, please explain.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
7. Does your system have an accumulation edit to prevent patients from continuously
filling prescriptions early?
Yes
No
If “Yes”, please explain your edit.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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If “No”, do you plan to implement this edit?
Yes
No
8. Does the state Medicaid Program 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
9. For drugs not on your Preferred Drug List (PDL) does your Medicaid Program have a
documented process (i.e. PA) in place, so that the Medicaid beneficiary or the
Medicaid beneficiary’s prescriber may access any covered outpatient drug when
medically necessary?
Yes
Please check all that apply.
Automatic PA based on diagnosis codes or systematic review
Trial and failure of first or second line therapies
Pharmacist or technician reviews
Direct involvement with Pharmacy and/or Medical Director
Other, please explain.
___________________________________________________________
____________________________________________________________
___________________________________________________________
No, please explain.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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a. Does your program provide for the dispensing of at least a 72-hour supply of a
covered outpatient drug (COD) in an emergency situation?
Yes
Please check all that apply.
Real time automated process
Retrospective prior authorization
Other process, please explain.
_________________________________________________________
________________________________________________________
_________________________________________________________
No, please explain.
_________________________________________________________
_________________________________________________________
_________________________________________________________
10. Please list the requested data in each category in Table 1: Top Drug Claims Data
Reviewed by the DUR Board below.
Column 1 – Top 10 PA Requests by Drug Name, report at generic ingredient level
Column 2 – Top 10 PA Requests by Drug Class
Column 3 – Top 5 Claim Denial Reasons (i.e. Quantity Limits (QL), Early Refill
(ER), PA, Therapeutic Duplications (TD), and Age Edits (AE))
Column 4 – Top 10 Drug Names by Amount Paid, report at generic ingredient level
Column 5 – From Data in column 4, determine the Percentage of Total Drug Spend
Column 6 – Top 10 Drug Names by Claim Count, report at generic ingredient level
Column 7 – From Data in Column 6, determine the Percentage of Total Claims
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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 Authorization (PA)
Requests by Drug Name, report at
generic ingredient level
Top 10 Prior Authorization
(PA) Requests by Drug Class
Top 5 Claim Denial Reasons Other Than
Eligibility (i.e. Quantity Limits (QL),
Early Refill (ER), PA, Therapeutic
Duplications (TD) and Age Edits (AE))
Top 10 Drug Names by Amount Paid,
report at generic ingredient level
% of Total
Spent for
Drugs by
Amount Paid
(From data in
Column 4,
Determine the
% of total
drug spend)
Top 10 Drug Names by Claim Count,
report at generic ingredient level
Drugs by
Claim Count
% of Total
Claims
(From data in
Column 6,
Determine the
% of total
claims)
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
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11. Section 1927(g)(A) of the Social Security Act (the Act) requires that the pharmacist
offer patient counseling at the time of dispensing. Who in your state has responsibility
for monitoring compliance with the oral counseling requirement? Check all that
apply.
Medicaid Program
State Board of Pharmacy
Other, please explain.
_________________________________________________________________
________________________________________________________________
________________________________________________________________
III.
RETROSPECTIVE DUR (RetroDUR)
Indicate the type of vendor that performed your RetroDUR activities during the time
period covered by this report.
Company
Academic Institution
Other Institution
a. Identify, by name, your RetroDUR vendor.
b. Is the RetroDUR vendor the Medicaid Management Information System (MMIS)
FA?
Yes
No
c. Is the RetroDUR vendor the developer/supplier of your RetroDUR criteria?
i. Yes, please explain.
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ii. No, please explain.
d. Do you customize your RetroDUR vender criteria?
Yes
No
Ad hoc based on state-specific needs
How often does your state perform retrospective practitioner based education?
Monthly
Bi-monthly
Quarterly
Other, please specify: _______________
How often do you perform retrospective reviews that involves communication
of client specific information to healthcare practitioner (through messaging, fax,
or mail)? Check all that apply.
Monthly
Bi-monthly
Quarterly
Other, please specify: ________________________________
What is the preferred mode of communication when performing RetroDUR
initiatives? Check all that apply.
Mailed letters
Provider phone calls
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Near real time fax
Near real time messaging
Other new technologies such as apps or Quick Response (QR) codes
Focused workshops, case management or WebEx training
Newsletters or other non-direct provider communications
Other, please specify: _________
Summary 1: RetroDUR Educational Outreach
Summary 1: RetroDUR Educational Outreach is a year-end summary report on
RetroDUR screening and educational interventions. The year-end summary
should be limited to the most prominent problems with the largest number of
exceptions. The results of RetroDUR screening and interventions should be
included and detailed below.
IV.
DUR BOARD ACTIVITY
1. Summary 2: DUR Board Activities Report
Summary 2: DUR Board Activities Report should be a brief descriptive on DUR
activities during the fiscal year reported. Please provide a detailed summary below:
•
•
Indicate the number of DUR Board meetings held.
List additions/deletions to DUR Board approved criteria:
o For ProDUR, list problem type/drug combinations added or deleted.
o For RetroDUR, 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.
Describe policies that establish whether and how results of RetroDUR
screening are used to adjust prospective DUR screens.
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FEE-FOR-SERVICE DRUG UTILIZATION REVIEW ANNUAL SURVEY
Describe DUR Board involvement in the DUR education program (i.e.
newsletters, continuing education, etc.).
Describe policies adopted to determine mix of patient or provider specific
intervention types (i.e. letters, face-to-face visits, increased monitoring).
2. Does your state have an approved Medication Therapy Management (MTM)
Program?
V.
Yes
No
PHYSICIAN ADMINISTERED DRUGS (PAD)
The Deficit Reduction Act required collection of National Drug Code (NDC) numbers for
covered outpatient physician administered drugs. These drugs are paid through the
physician and hospital programs. Has your MMIS been designed to incorporate this data
into your DUR criteria for:
1. ProDUR?
Yes
No
If “No”, do you have a plan to include this information in your DUR criteria in the
future?
Yes
No
2. RetroDUR?
Yes
No
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If “No”, do you have a plan to include this information in your DUR criteria in the
future?
VI.
Yes
No
GENERIC POLICY AND UTILIZATION DATA
1. Summary 3: Generic Drug Substitution Policies
Summary 3: Generic Drug Substitution Policies summarizes should summarize factors
that could affect your generic utilization percentage. In describing these factors, please
explain any formulary management or cost containment measures, PDL policies,
educational initiatives, technology or promotional factors, or other state specific factors
that affects your generic utilization rate.
2. 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 state 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 to accompany the prescription(s)
PA is required
Other, please explain.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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Table 2: Generic Drug Utilization Data
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.
1. 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
2. Generic Expenditures Percentage of Total Drug Expenditures: To determine
the generic expenditure percentage (rounded to the nearest $1000) for all covered
outpatient drugs for this reporting period use the following formula:
$N ÷ ($S + $N + $I) × 100 = Generic Expenditure Percentage
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, which can be found at Medicaid.gov (Click on the link “an NDC and Drug
Category file [ZIP],” then open the Medicaid Drug Product File 4th Qtr. 2020 Excel
file).
Please provide the following utilization data for this DUR reporting period for all covered
outpatient drugs paid. Exclude Third Party Liability (TPL).
Single Source (S)
Drugs
Non-Innovator (N)
Drugs
Innovator Multi-Source (I)
Drugs
Total Number of Claims
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Single Source (S)
Drugs
Non-Innovator (N)
Drugs
Innovator Multi-Source (I)
Drugs
Total Reimbursement
Amount Less Co-Pay
3. Indicate the generic utilization percentage for all CODs 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
______________%
4. How many multi source drugs have the innovator as the preferred drug product based
on net pricing?
____________
5. Indicate the percentage dollars paid for generic covered outpatient drugs in relation
to all covered outpatient drug claims paid during this reporting period using the
computation instructions in Table 2: Generic Utilization Data
Generic Dollars:
$______________
Total Dollars:
$______________
Generic Expenditure Percentage:
_______________%
6. Does your state have any policies related to Biosimilars? Please explain.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
VII.
PROGRAM EVALUATION/ COST SAVINGS/ COST AVOIDANCE
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1. Did your state conduct a DUR program evaluation of the estimated cost savings/cost
avoidance?
Yes
No
If “Yes”, identify, by name and type, the institution that conducted the program
evaluation.
Institution Type
Company
Academic Institution
Other Institution
Institution Name
______________________________________________________________
2. Please provide your ProDUR and RetroDUR program cost savings/cost avoidance in
the chart below.
Data
ProDUR Total Estimated Avoided Costs
RetroDUR Total Estimated Avoided Costs
Other Cost Avoidance
Grand Total Estimated Avoided Costs
3. The Estimated Percent Impact was generated by dividing the Grand Total Estimated
Avoided Costs from Question 2 above by the Total Dollar Amount provided in
Section VI, Question 4, then multiplying this value by 100.
Estimated Percent Impact:
________%
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4. Summary 4: Cost Savings/Cost Avoidance Methodology
Summary 4 Cost Savings/Cost Avoidance Methodology includes program
evaluations/cost savings estimates prepared by state or contractor. Please provide
detailed summary below.
__________________________________________________________________________
_____________________________________________________________________
VIII.
FRAUD, WASTE, AND ABUSE (FWA) 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 PA
Refer to Lock-In Program
Refer to Program Integrity Unit (PIU)/Surveillance Utilization Review
(SUR) Unit
Refer to Office of Inspector General (OIG)
Other, please explain.
2. Do you have a Lock-In program for beneficiaries with potential misuse or abuse of
controlled substances?
Yes
No
If Yes, please continue.
a. What criteria does your state use to identify candidates for Lock-In? Check all
that apply.
Number of controlled substances (CS)
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Different prescribers of CS
Multiple pharmacies
Number days’ supply of CS
Exclusivity of short acting opioids
Multiple ER visits
PDMP data
Other, please explain.
____________________________________________________________
____________________________________________________________
____________________________________________________________
b. Do you have the capability to restrict the beneficiary to:
i. Prescriber only
Yes
No
ii. Pharmacy only
Yes
No
iii. Prescriber and pharmacy
Yes
No
c. On average, what percentage of the FFS population is in Lock-In status
annually?
_______%
3. Do you have a documented process in place that identifies possible FWA of
controlled drugs by prescribers?
Yes
What actions does this process initiate? Check all that apply.
Deny claims written by this prescriber
Refer to Program Integrity Unit
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Refer to the appropriate Medical Board
Other, please explain.
____________________________________________________________
____________________________________________________________
____________________________________________________________
No, please explain.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Do you have a documented process in place that identifies potential FWA of
controlled drugs by pharmacy providers?
Yes
What actions does this process initiate? Check all that apply.
Deny claim
Refer to Program Integrity Unit
Refer to Board of Pharmacy
Other, please explain.
____________________________________________________________
____________________________________________________________
____________________________________________________________
No, please explain.
____________________________________________________________
____________________________________________________________
____________________________________________________________
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5. Do you have a documented process in place that identifies and/or prevents potential
FWA of non-controlled drugs by beneficiaries?
Yes, please explain your program for fraud, waste or abuse of non-controlled
substances.
____________________________________________________________
____________________________________________________________
____________________________________________________________
No, please explain.
________________________________________________________________
__________________________________________________________________
__________________________________________________________________
B. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
Note: Section 5042 of the SUPPORT for Patients and Communities Act requires states to
report metrics in reference to their state’s PDMP. CMS has included questions to reference
these metrics to help your state establish processes to be in compliance with provisions
outlined in Section 5042 and CMS reporting, beginning in FFY 2023. Please complete
applicable questions below in this section of the survey.
1. Does your Medicaid Program have the ability to query the state’s PDMP database?
Yes, receive PDMP data
Daily
Weekly
Monthly
Other ______________
Yes, have direct access to the database
Can query by client
Can query by prescriber
Can query by dispensing entity
No
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If “Yes”, please continue.
a. Please explain how the state applies this information to control FWA of
controlled substances.
b. Do you also have access to Border States’ PDMP information?
Yes
No
c. Do you also have PDMP data integrated into your POS edits?
Yes
No
2. Do you or your professional board require prescribers to access the PDMP patient
history before prescribing controlled substances?
Yes
No
If “Yes”, please continue.
a. Are there protocols involved in checking the PDMP?
Yes, please explain.
No
b. Are providers required to have protocols for responses to information
from the PDMP that is contradictory to the direction that the
practitioner expects from the client?
Yes
No
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c. If a provider is not able to conduct PDMP check, do you require the
prescriber to document a good faith effort, including the reasons why
the provider was not able to conduct the check?
Yes
No, please explain.
If “Yes”, do you require the provider to submit, upon request,
documentation to the State?
Yes
No, please explain.
3. Does the State require pharmacists to check the PDMP prior to dispensing?
Yes
No, please explain.
If “Yes”, are there protocols involved in checking the PDMP?
Yes, please explain.
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No
4. In the State’s PDMP system, which of the following pieces of information with
respect to a beneficiary, is available to prescribers as close to real-time as
possible? Check all that apply.
PDMP drug history
The number and type of controlled substances prescribed to and dispensed
to the beneficiary during at least the most recent 12-month period.
The name, location, and contact information, or other identifying number,
such as a national provider identifier, for previous beneficiary fills
Other, please explain.
a. Are there barriers that hinder the Medicaid Program from fully accessing the
PDMP that prevent the program from being utilized the way it was intended to
be to curb fraud and abuse?
Yes, please explain the barriers (i.e. lag time in prescription data being
submitted, prescribers not accessing, pharmacists unable to view
prescription history before filling script).
No
5. Please specify below the following information for the 12-month reporting period
for this survey. Note: Mandatory reporting will be required in FFY2023 under
section 1927(g)(3)(D) of the Act.
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a. The percentage of covered providers who checked the prescription drug history of
a beneficiary through a PDMP before prescribing a controlled substance to such
an individual:
_______%.
b. Average daily MME prescribed for controlled substances per covered individuals:
_______MMEs
c. Average daily MME prescribed for controlled substances per covered individuals
who are receiving opioids.
_______MMEs
d. Please complete Tables 3, 4, 5 and 6 below. Specify the controlled substances
prescribed based on claim count (by generic ingredient(s)) and within each
population during this FFY reporting period.
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Table 3: Opioid Controlled Substances by Population
Population
Top 3 Opioid
Controlled Substances
Prescribed Based On
Claim Count (Generic
Ingredient) within
Each Population
Number of
Beneficiaries in
Total Number
Each
of Beneficiaries
Population/
Within Each
Month Receiving
Population
Controlled
Substances
Percentage of
Population
Receiving
Controlled
Substances
(Auto Calculate)
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals with
Disabilities
Utilizing State
Eligibility
Categories
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Table 4: Top Sedative/Benzodiazepines Controlled Substances by Population
•
When listing the controlled substances in different drug categories, for the purpose of Table 4
below, please consider long and short acting benzodiazepines to be in the same category.
Population
Number of
Top 3 Sedative/
Beneficiaries in
Total
Benzodiazepine Controlled
Each Population/
Number of
Substances Prescribed
Month Receiving
Beneficiaries
Based On Claim Count
Sedative/
within Each
(Generic Ingredient)
Benzodiazepine
Population
within Each Population
Controlled
Substances
Percentage of
Population
Receiving
Sedative/
Benzodiazepine
Controlled
Substances
(Auto Calculate)
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals
with
Disabilities
Utilizing State
Eligibility
Categories
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Table 5: Top Stimulant/ADHD Controlled Substances by Population
•
When listing the controlled substances in different drug categories, for the purpose of Table 5 below, please
consider long and short acting ADHD medications to be in the same category.
Population
Top 3 Stimulant/ADHD
Controlled Substances
Prescribed Based On
Claim Count (Generic
Ingredient) within Each
Population
Number of
Total
Beneficiaries In
Number of Each Population/
Beneficiaries Month Receiving
within Each Stimulant/ADHD
Population
Controlled
Substances
Percentage of
Population
Receiving
Stimulant/ADHD
Controlled
Prescriptions
(Auto Calculate)
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals
with
Disabilities
Utilizing State
Eligibility
Categories
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Table 6: Populations on 2 or more Controlled Substances in Different Drug Categories
•
When listing the controlled substances in different drug categories, for the purpose of Table 6
below, please consider long and short acting opioids to be in the same category. Please follow this
approach for long and short acting ADHD medications and benzodiazepines in this table as well.
Population
Total
Number of
Beneficiaries
within Each
Population
Number of Beneficiaries
in Each Population/
Month Receiving 2 or
more Controlled
Substances in Different
Drug Categories
Number of Beneficiaries
in Each Population/
Month Receiving 3 or
more Controlled
Substances in Different
Drug Categories
Percentage of
Population
Receiving 2 or
more Controlled
Substances
(Auto Calculate)
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals
with
Disabilities
Utilizing State
Eligibility
Categories
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i. If there is additional information you want to provide for the previous 12month reporting period, please explain below.
ii. If any of the information requested is not being reported above, please explain
below.
5. Have you had any changes to your state’s PDMP during this reporting period that
have improved the Medicaid Program’s ability to access PDMP data?
Yes, please explain.
___________________________________________________________
___________________________________________________________
No
6. In this reporting period, have there been any data or privacy breaches of the PDMP
or PDMP data?
Yes
No
If “Yes”, please summarize the breach, the number of individuals impacted, a
description of the steps the State has taken to address each such breach, and if
law enforcement or the affected individuals were notified of the breach.
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C. 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
Please explain responses above.
If the answer to question 1 is “Yes, for all opioids” or “Yes, for some opioids,” please
continue.
a. Is there more than one quantity limit for various opioids? Additionally, please
explain ramifications when addressing COVID-19 if applicable.
Yes, please explain.
No
b. What is the maximum number of days allowed for an initial opioid
prescription for an opioid naïve patient?
______ # of days
c. Does this days’ supply limit apply to all opioid prescriptions?
Yes, for all opioids
Yes, for some opioids
No
Please explain above response.
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_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. For subsequent prescriptions, do you have POS edits in place to limit the quantity
dispensed of short-acting (SA) opioids?
Yes
What is your maximum days’ supply per prescription limitation?
30-day supply
34-day supply
90-day supply
Other, please explain.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
No, please explain
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. Do you currently have POS edits in place to limit the quantity dispensed of longacting (LA) opioids?
Yes
What is your maximum days’ supply per prescription limitation?
30-day supply
34-day supply
90-day supply
Other, please explain.
_______________________________________________________________
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_______________________________________________________________
_______________________________________________________________
No, 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 Milligram Equivalent (MME) daily dose program
Step therapy or Clinical criteria
Requirement that patient has a pain management contract or Patient-Provider
agreement
Requirement that prescriber has an opioid treatment plan for patients
Require documentation of urine drug screening results
Require diagnosis
Require PDMP checks
Workgroups to address opioids
Other, please specify
Please provide details on these opioid prescribing controls in place.
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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 have POS edits to monitor duplicate therapy of opioid prescriptions? This
excludes regimens that include a single extended release product and a breakthrough
short acting agent.
Yes
No
Please explain above response.
6. Do you have POS edits and automated claim retrospective reviews to monitor
duplicate therapy of opioid prescriptions dispensed?
Yes, POS edits
Yes, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
No
If any response is “Yes”, please explain scope and nature.
If “No”, please explain.
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7. Do you have POS edits and automated claim retrospective reviews to monitor early
refills of opioid prescriptions dispensed?
Yes, POS edits
Yes, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
No
If any response is “Yes”, please explain scope and nature of reviews and edits in
place.
If “No”, please explain.
8. Do you have a comprehensive automated retrospective claims review process to
monitor opioid prescriptions exceeding these state limitations?
Yes, please explain in detail scope and nature of these retrospective reviews.
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No, please explain.
9. Do you currently have POS edits in place or a retrospective claims review to monitor
opioids and benzodiazepines being used concurrently?
Yes, POS edits
Yes, retrospective claim reviews
Yes, both POS edits and retrospective claim reviews
Please explain above response and detail the scope and nature of these reviews and
edits. Additionally, please explain any potential titration processes utilized for
those patients chronically on benzodiazepines and how the state justifies pain
medications, i.e. Oxycodone/APAP, for breakthrough pain without jeopardizing
patient care (i.e. quantity limits/practitioner education titration programs).
No, please explain.
10. Do you currently have POS edits in place or a retrospective claims review to
monitor opioids and sedatives being used concurrently?
Yes, POS edits
Yes, retrospective reviews
Yes, both POS edits and retrospective claim reviews
Please explain response above and detail scope and nature of reviews and edits.
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No, please explain.
11. Do you currently have POS edits in place or a retrospective claims review to
monitor opioids and antipsychotics being used concurrently?
Yes, POS edits
Yes, retrospective claim reviews
Yes, both POS edits and retrospective claim reviews
Please explain above response and detail scope and nature of reviews and edits.
No, please explain.
12. Do you have POS safety edits or perform retrospective DUR activity and/or
provider education in regard to beneficiaries with a diagnosis history of opioid use
disorder (OUD) or opioid poisoning diagnosis?
Yes, POS edits
Yes, RetroDUR activity and/or provider education
Yes, both POS edits and RetroDUR activity and/or provider education
No
If “Yes, RetroDUR activity and/or provider education”, please indicate how often.
Monthly
Quarterly
Semi-Annually
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Annually
Ad hoc
Other, please specify.
Please explain the nature and scope of edits, reviews and/or provider
education reviews performed.
If “No”, do you plan on implementing RetroDUR activity and/or provider
education in regard to beneficiaries with a diagnosis history of OUD or opioid
poisoning in the future?
Yes, when do you plan on implementing?
No, please explain.
13. Does your state Medicaid Program develop and provide prescribers with pain
management or opioid prescribing guidelines?
Yes
No
If “Yes”, please check all that apply.
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Your state Medicaid Program refers prescribers to the Center for
Disease Control (CDC) Guideline for Prescribing Opioids for Chronic
Pain.
Other guidelines, please identify.
If “No”, please explain why no guidelines are offered.
14. 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
D. MORPHINE MILLIGRAM EQUIVALENT (MME) DAILY DOSE
1. Have you set recommended maximum MME daily dose measures?
Yes
No
If “Yes”, please continue.
a. What is your maximum MME daily dose limit in milligrams?
Less than 50 MME, please specify:
50 MME
70 MME
80 MME
mg per day
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90 MME
100 MME
120 MME
200 MME
Greater than 200 MME, please specify.
Other: Please specify: _______ mg per day
mg per day
b. Please explain nature and scope of dose limit (i.e. who does the edit apply
to? Does the limit apply to all opioids? Are you in the process of tapering
patients to achieve this limit)?
If “No,” please explain the measure or program you utilize.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. Do you have an edit in your POS system that alerts the pharmacy provider that the
MME daily dose prescribed has been exceeded?
Yes
No
If “Yes”, do you require prior authorization if the MME limit is exceeded?
Yes
No
3. Do you have automated retrospective claim reviews to monitor the MME total daily
dose of opioid prescriptions dispensed?
Yes, please explain.
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No, please explain.
E. OPIOID USE DISORDER (OUD) TREATMENT
1. Do you have utilization controls (i.e. PDL, PA, QL) to either monitor or manage the
prescribing of Medication Assisted Treatment (MAT) drugs for OUD?
Yes, please explain.
No
2. Does your Medicaid Program 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
32 mg
Other, please explain.
3. What are your limitations on the allowable length of this treatment?
No limit
3 months or less
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6 months
12 months
24 months
Other, please explain.
4. Do you require that the maximum mg per day allowable be reduced after a set period
of time?
Yes
No
If “Yes”, please continue.
a. What is your reduced (maintenance) dosage?
8 mg
12 mg
16 mg
Other, please explain.
b. What are your limitations on the allowable length of the reduced dosage
treatment?
6 months
12 months
No limit
Other, please explain.
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5.
Do you have at least one buprenorphine/naloxone combination product available
without prior authorization?
6.
FEE-FOR-SERVICE DRUG UTILIZATION REVIEW ANNUAL SURVEY
Yes
No
Do you currently have edits in place to monitor opioids being used concurrently with
any buprenorphine drug or any form of MAT?
Yes
No
Other, please explain.
If “Yes”, can the POS pharmacist override the edit?
Yes
No
7. Is there at least one formulation of naltrexone for OUD available without PA?
8.
Yes
No
Do you have at least one naloxone opioid overdose product available without PA?
Yes
No
9. Do you retrospectively monitor and manage appropriate use of naloxone to persons at
risk of overdose?
Yes
No, please explain.
10. Does your State Board of Professional Regulations/Board of Pharmacy/Board of
Medicine and/or state Medicaid Program allow pharmacists to dispense naloxone
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prescribed independently or by collaborative practice agreements, standing orders, or
other predetermined protocols?
Yes, State Board of Professional Regulations/Board of Pharmacy/Board of
Medicine and/or State Medicaid Program under protocol
Yes, prescribed independently
No
F. OUTPATIENT TREATMENT PROGRAMS (OTP)
1. Do your state cover outpatient treatment programs that provide both services,
Behavioral Health (BH) and MAT through OTPs?
Yes
No, please explain.
If “Yes”, is a referral needed for OUD treatment through OTPs?
Yes, please explain.
No, please explain.
2. Does your state Medicaid Program cover buprenorphine or
buprenorphine/naloxone for diagnoses of OUD as part of a comprehensive MAT
treatment plan through OTPs?
Yes
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No, please explain.
3. Does your state Medicaid Program cover naltrexone for diagnoses of OUD as part
of a comprehensive MAT treatment plan?
Yes
No, please explain.
4. Does your state Medicaid Program cover Methadone for a substance use disorder
(i.e. OTPs, Methadone Clinics)?
Yes
No
G. ANTIPSYCHOTICS /STIMULANTS
ANTIPSYCHOTICS
1. Do you currently have restrictions in place to limit the quantity of antipsychotics?
Yes
No
Enter restrictions other than quantity limits below, or N/A.
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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.
a. Do you either manage or monitor?
Only children in foster care
All children
Other, please explain.
b. Do you have edits in place to monitor (check all that apply)?
Child’s Age
Dosage
Indication
Polypharmacy
Other, please explain.
c. Please briefly explain the specifics of your antipsychotic monitoring
program(s).
If “No”, please continue.
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d. Do you plan on implementing a program in the future?
Yes, please specify when.
_______________________________________________________________
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 “Yes”, please continue.
a. Do you either manage or monitor?
Only children in foster care
All children
Other, please explain.
b. Do you have edits in place to monitor (check all that apply)?
Child’s Age
Dosage
Indication
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Polypharmacy
Other, please explain.
c. Please briefly explain the specifics of your documented stimulant monitoring
program(s).
If “No”, please continue.
d. Do you plan on implementing a program in the future?
IX.
Yes, please specify when.
No, please explain why you will not be implementing a program to
monitor the appropriate use of stimulant drugs in children.
INNOVATIVE PRACTICES
1. Does your state participate in any demonstrations or have any waivers to allow
importation of certain drugs from Canada or other countries that are versions of FDAapproved drugs for dispensing to Medicaid Beneficiaries?
Yes, please explain.
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No
2. Summary 5: Innovative Practices
Summary 5: Innovative Practices should discuss development of innovative practices
during the past year (i.e. Substance Use Disorder, Hepatitis C, Cystic Fibrosis, MME,
and Value Based Purchasing). Please describe in detailed narrative below 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).
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
X.
MANAGED CARE ORGANIZATIONS (MCOs)
1. How many MCOs are enrolled in your state Medicaid program?
____________MCO(s) (Insert the number of MCOs in the space provided including 0 if none)
If “Zero” or “None”, please skip the rest of this section.
2. Is your pharmacy program included in the capitation rate (carved in)?
Yes
No
Partial
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Please specify the drug categories that are carved out.
3. Contract updates between state and MCOs addressing DUR provisions in Section
1004 Support for Patients and Communities Act are required based on 1902(oo). If
covered outpatient drugs are included in an MCO’s covered benefit package, has the
State updated their MCOs’ contracts for compliance with Section 1004 of the
SUPPORT for Patients and Communities Act?
Yes, contracts are updated to address each provision. Please specify effective
date:
__________________________________________________________________
No, contracts are not updated, please explain:
a. Is the state complying with Federal law and monitoring MCO compliance
on SUPPORT for Patients and Communities Act provisions?
Yes, state is complying with Federal law and monitoring MCO
compliance on SUPPORT for Patients and Communities Act
provisions. Please explain monitoring activities.
No, please explain.
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4. Does the state set requirements for the MCO’s pharmacy benefit (i.e. same PDL,
same ProDUR/RetroDUR)?
Yes
No
If “Yes”, please continue.
a) Please check all requirements that apply below.
Formulary Reviews
Same PDL
Same ProDUR
Same RetroDUR
No State PDL
b) Please briefly explain your policy.
If “No”, do you plan to set standards in the future?
Yes
No, please explain.
5. Is the RetroDUR program operated by the state or by the MCOs or does your state
use a combination of state interventions as well as individual MCO interventions?
State operated
MCO operated
State uses a combination of state interventions as well as individual MCO
interventions
6. Indicate how the State oversees the FFS and MCO RetroDUR programs? Please
explain oversight process.
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7. How does the state ensure MCO compliance with DUR requirements described in
Section 1927(g) of the Act and 42 CFR part 456, subpart K?
8. Did all of your managed care plans submit their DUR reports?
XI.
Yes
No, please explain.
EXECUTIVE SUMMARY
Summary 6: Executive Report should provide a brief overview of your program. It
should describe 2019 highlights of the program, FFS initiatives, improvements, program
oversight of managed care partners when applicable, and statewide (FFS and MCO)
initiatives.
52
| File Type | application/pdf |
| File Title | PRA_FFS DUR Annual Report Survey_FFY 2020_Final |
| Author | Yolonda Williams |
| File Modified | 2020-07-15 |
| File Created | 2020-07-09 |