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pdfFFY 2020
MANAGED CARE ORGANIZATION DRUG UTILIZATION REVIEW ANNUAL SURVEY
ABOUT THE SURVEY
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.
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. Answering the attached questions and
returning the requested materials as attachments to the report will constitute compliance with the abovementioned statutory and regulatory requirements.
If you have any questions regarding the DUR Annual Report, please contact your state’s Medicaid Pharmacy
Program.
IMPORTANT NOTE: Adobe Acrobat Reader must be used to edit the survey. The MCO survey cannot be
edited within a browser window.
Pursuant to 42 C.F.R. Subpart A, Section § 438.3 (s), Medicaid managed care programs must submit to CMS
an annual report on the operation of its DUR program activities for that Federal Fiscal Year (FFY). Beginning
with FFY 2020 surveys, individual managed care plan’s survey results will be published online and will be
publically available similar to the FFS surveys which have been published on Medicaid.gov since
2010. Please confirm and acknowledge there is no proprietary or confidential information submitted
in this report by checking the box below:
o I confirm I am aware this survey will be posted online. Confidential and proprietary information has
been removed from this survey.
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 0938-0659 (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 C426-05, Baltimore, Maryland 21244-1850.
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FFY 2020
I.
MANAGED CARE ORGANIZATION DRUG UTILIZATION REVIEW ANNUAL SURVEY
DEMOGRAPHIC INFORMATION
State Abbreviation: _______
MCO Name:
______________________________________________________________
Please Note: Name above must match name entered in Medicaid Drug Program (MDP) DUR system
Program Type (See Appendix A): ___________________________________________
If “Other”, please specify.
____________________________________________
Medicaid MCO Information
Identify the 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
II.
PROSPECTIVE DUR (ProDUR)
1. 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.
__________________________________________________________________
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2. Identify 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.
3. 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 “National
Council for Prescription Drug Program (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 to be overridden.
Other, please explain.
______________________________________________________
4. Do you receive periodic reports providing individual pharmacy provider DUR alert
override activity in summary and/or in detail?
Yes
a. How often?
Monthly
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Quarterly
Annually
Ad hoc (on request)
Other, please explain.
b. 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 (PI) for Review
Other, please explain.
No
No, please explain.
5. Early Refill
a. At what percent threshold do you set your system to edit?
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i. Non-controlled drugs:
______ %
ii. Schedule II controlled drugs:
______ %
iii. Schedule III through V controlled drugs:
______ %
b. For non-controlled drugs:
When an early refill message occurs, does your MCO require prior authorization
(PA)?
Yes
No
Dependent on the 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 point of service?
Yes
No
c. For controlled drugs:
When an early refill message occurs, does your MCO require PA?
Yes
No
If “Yes”, who obtains authorization?
Pharmacist
Prescriber
Pharmacist or Prescriber
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If “No”, can the pharmacist override at the point of service?
Yes
No
6. When the pharmacist receives an early refill DUR alert message that requires the
pharmacist’s review, does your 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
b. Vacation
Yes
No
Overrides are only allowed by a pharmacist through a PA
c. 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 edits.
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If “No”, do you plan to implement this edit?
Yes
No
8. 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
9. For drugs not on your MCO’s Preferred Drug List (PDL), does your MCO 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.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
a. How does your MCO ensure PA criteria is no more restrictive than the FFS
criteria and review? Please describe the process.
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b. Does your program provide for the dispensing of at least a 72-hour supply of
CODs 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 (See
Appendix B for the list of Drug Names)
Column 2 – Top 10 PA Requests by Drug Class (See Appendix C for Drug Class names)
Column 3 – Top 5 Claim Denial Reasons (i.e. Quantity Limits (QL), Early Refill (ER),
PA, Therapeutic Duplications (TD), and Age Edits (AE) (See Appendix D
for the list of Denial Reasons)
Column 4 – Top 10 Drug Names by Amount Paid, report at generic ingredient level (See
Appendix B for the list of Drug Names)
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 (See
Appendix B for the list of Drug Names)
Column 7 – From Data in Column 6, determine the Percentage of Total Claim
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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, Early
Refill, PA,
Therapeutic
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,
Top 10 Drug
Names by
Claim Count,
report at
generic
ingredient
level
Drugs by Claim
Count
Duplications,
Age Edits)
Determine the
% of total drug
spend)
% of Total
Claims (From
data in Column
6, Determine the
% of total
claims)
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
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III.
MANAGED CARE ORGANIZATION DRUG UTILIZATION REVIEW ANNUAL SURVEY
RETROSPECTIVE DUR (RetroDUR)
1. Please indicate how your MCO operates and oversees RetroDUR reviews?
State-operated interventions
Managed Care executes its own RetroDUR activities
Pharmacy Benefit Manager (PBM) performs RetroDUR activities
Combination of MCO RetroDUR interventions and state interventions are performed
Other, please explain.
2. 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 developer/supplier of your RetroDUR criteria?
i.
Yes, please explain.
ii.
No, please explain.
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c. Do you customize your RetroDUR vender criteria?
Yes
No
Ad hoc based on state-specific needs
3. Who reviews and approves the RetroDUR criteria?
State DUR Board
MCO DUR Board
PBM performs RetroDUR and has a RetroDUR Board
PBM Pharmacy and Therapeutics (P&T) Board also functions as a DUR Board
State Pharmacy Director
Other, please explain.
4. How often does your MCO perform retrospective practitioner based education?
Monthly
Bi-monthly
Quarterly
Other, please specify: _______________
a. 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
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Other, please specify: _____________________________________
b. What is the preferred mode of communication when performing RetroDUR
initiatives (check all that apply)?
Mailed letters
Provider phone calls
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:
_________________________________________________________
_________________________________________________________
5. Summary 1: RetroDUR Educational Outreach
Summary 1: RetroDUR Educational Outreach is a year-end summary report on
RetroDUR screening and educational interventions. The summary should be limited to
the most prominent problems with the largest number of exceptions. The results of
retrospective DUR screening and interventions should be included and detailed below.
________
______________________
__________________________________________________________________________
____________________________________________________________________
____________________________________________________________________
IV.
DUR BOARD ACTIVITY
1. Does your MCO utilize the same DUR Board as the state Fee-For-Service (FFS)
Medicaid Program or does your MCO have its own DUR Board?
Same DUR Board as FFS agency
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MCO has its own DUR Board
Other, please explain.
2. Summary 2: DUR Board Activities Report
Summary 2: DUR Board Activities Report should be a brief descriptive report 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 ProDUR
screening are used to adjust RetroDUR screens.
Describe policies that establish whether and how results of RetroDUR
screening are used to adjust ProDUR screens.
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 MCO have a Medication Therapy Management (MTM) Program?
Yes
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V.
MANAGED CARE ORGANIZATION DRUG UTILIZATION REVIEW ANNUAL SURVEY
No
PHYSICIAN ADMINISTERED DRUGS (PAD)
The Deficit Reduction Act requires 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 pharmacy system 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
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.
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_________
_
______________________
_____________________________________________________________________________
_____________________________________________________________________________
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 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(s)
PA is required
Other, please explain.
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Table 2: Generic Drug Utilization
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).
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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
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 State’s preferred drug product
based on net pricing?
____________
5. Indicate the percentage dollars paid for generic covered outpatient drugs in relation
to all COD 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 MCO have any policies related to Biosimilars? Please explain.
_____________________________________________________________
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_____________________________________________________________
_____________________________________________________________
VII.
FRAUD, WASTE, AND ABUSE DETECTION (FWA)
A. LOCK-IN or PATIENT REVIEW AND RESTRICTIONPROGRAMS
1. Do you have a documented process in place that identifies potential FWA 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 FWA of controlled
substances?
Yes
No
If “No”, skip to question 3.
If “Yes”, please continue.
a. What criteria does your MCO use to identify candidates for Lock-In? Check
all that apply.
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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.
b. Do you have the capability to restrict the beneficiary to:
i.
Prescriber only
ii.
Pharmacy only
iii.
Yes
No
Prescriber and pharmacy
c.
Yes
No
Yes
No
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 FWA of controlled
drugs by prescribers?
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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.
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 claims
Refer to Program Integrity Unit
Refer to the 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 FWA 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 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 state have a PDMP?
Yes
No, please explain and go to Section C.
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If “Yes”, please continue.
a. Does your MCO 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
If “Yes”, please continue.
i. Please explain how your program applies this information to control
FWA of controlled substances.
ii. Does your MCO have access to border states’ PDMP information?
Yes
No
iii. Are there barriers that hinder your MCO from fully accessing the
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PDMP that prevent the program from being utilized the way it was
intended to be to curb FWA?
Yes, please explain the barriers that exist.
No
iv. Do you also have PDMP data integrated into your POS edits?
Yes
No
2. Do you or the professional board require prescribers (in your provider agreement) 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?
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Yes
No
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 MCO?
Yes
No, please explain.
3. Does your MCO 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.
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.
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
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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
Total Number
of Beneficiaries
Within Each
Population
Number of
Beneficiaries in
Each
Population/
Month Receiving
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
Top 3 Sedative/
Benzodiazepine
Controlled Substances
Prescribed Based On
Claim Count (Generic
Ingredient) within Each
Population
Total
Number of
Beneficiaries
within Each
Population
Number of
Beneficiaries in
Each Population/
Month Receiving
Sedative/
Benzodiazepine
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
Total
Number of
Number of
Beneficiaries In
Beneficiaries Each Population/
within Each Month Receiving
Population Stimulant/ADHD
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 12-month
reporting period, please explain below.
ii. If any of the information requested is not being reported above, please explain
below.
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.
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.
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If “No”, skip to question 1b.
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, some opioids
No
Please explain response above.
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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 long-acting
(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 response above.
6. Do you have POS edits and automated retrospective claim 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.
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If “No”, please explain.
7. Do you have POS edits and automated retrospective claim 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.
If “No”, please explain.
8. Do you have a comprehensive automated retrospective claims review process to monitor
opioid prescriptions exceeding state limitations?
Yes, please explain in detail the 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, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
Please explain the 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 an automated retrospective claims review to
monitor opioids and sedatives being used concurrently?
Yes, POS edits
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Yes, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
Please explain above response and detail the scope and nature of reviews and/or
edits.
No, please explain.
11. Do you currently have POS edits in place or an automated retrospective claims review to
monitor opioids and antipsychotics being used concurrently?
Yes, POS edits
Yes, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
Please explain above response and detail the scope and nature of reviews and/or
edits.
No, please explain.
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12. Do you have POS safety edits or perform RetroDUR 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 continue.
a. Please indicate how often.
Monthly
Quarterly
Semi-Annually
Annually
Ad hoc
Other, please specify.
b. 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?
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Yes, when do you plan on implementing?
No, please explain.
13. Does your MCO program develop and provide prescribers with pain management or
opioid prescribing guidelines?
Yes
No
If “Yes”, please check all that apply.
Your prescribers are referred to the Center for Disease Control (CDC)
Guideline for Prescribing Opioids for Chronic Pain
Other guidelines, please identify.
No guidelines are offered, please explain.
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.
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D.
MANAGED CARE ORGANIZATION DRUG UTILIZATION REVIEW ANNUAL SURVEY
No
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
90 MME
100 MME
120 MME
200 MME
Greater than 200 MME, please specify.
Other, please specify.
mg per day
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.
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_______________________________________________________________
_______________________________________________________________
____________________________________________________________________
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 PA if the MME limit is exceeded?
Yes
No
3. Do you have automated retrospective claim reviews to monitor total daily dose (MME)
of opioid prescriptions dispensed?
E.
Yes, please explain.
No, please explain.
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.
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No
2. 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
32mg
Other, please explain.
3. What are your limitations on the allowable length of this treatment?
No limit
3 months or less
6 months
12 months
24 months
Other, please explain.
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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.
5. Do you have at least one buprenorphine/naloxone combination product available without
prior authorization?
Yes
No
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6. 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?
Yes
No
8. 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 above response.
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10. Does your MCO allow pharmacists to dispense naloxone prescribed independently or by
collaborative practice agreements, standing orders, or other predetermined protocols?
Yes, please explain.
No
F. OUTPATIENT TREATMENT PROGRAMS (OTP)
1. Does your MCO cover OTPs 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.
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2. Does your MCO cover buprenorphine or buprenorphine/naloxone for diagnoses of
OUD as part of a comprehensive MAT treatment plan through OTPs?
Yes
No, please explain.
3. Does your MCO cover naltrexone for diagnoses of OUD as part of a comprehensive
MAT treatment plan?
Yes
No, please explain.
4. Does your MCO cover Methadone for SUD (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
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No
Enter restrictions other than quantity limits below, or N/A.
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 “No”, skip to question 2.d.
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.
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c. Please briefly explain the specifics of your antipsychotic monitoring
program(s).
If “No”, please continue.
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
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If “No”, skip to question 4.d.
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 documented stimulant monitoring
program(s).
If “No”, please continue.
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d. If you do not have a documented stimulant monitoring program in place, 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 stimulant drugs in children.
VIII. INNOVATIVE PRACTICES
1. Does your MCO participate in any demonstrations or have any waivers to allow importation
of certain drugs from Canada or other countries that are versions of FDA-approved drugs for
dispensing to Medicaid Beneficiaries?
Yes, please explain.
No
2. Summary 4: Innovative Practices
Have you developed any innovative practices during the past year (i.e. Substance Use
Disorder, Hepatitis C, Cystic Fibrosis, MMEs, 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).
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________________________
________________________________________________________________________
________________________________________________________________________
IX. EXECUTIVE SUMMARY
Summary 5: Executive Summary
Please include a general overview and summary of program highlights from FFY 2019 as
well as objectives, tools and outcomes of initiatives accomplished, as well as goals for FFY
2020. Include a summary of program oversight and initiatives.
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APPENDIX A: MCO PROGRAM TYPES
DEFINITIONS OF MANAGED CARE PROGRAM TYPES
A managed care program is defined by the set of benefits covered and the type of participating
managed care plans (e.g., MCOs, PHPs, PACE, etc.) or providers (e.g., PCCM providers).
Managed Care
Program Type
Definition
Comprehensive Managed Care Organization: A program in which the State
contracts with managed care plans to cover all acute and primary medical
services; some also cover behavioral health, dental, transportation and long
term care. Entities that qualify as MCOs include Health Maintenance
Organizations (HMOs) and Health Insuring Organizations (HIOs in
California).
If the comprehensive MCO also covers long-term services and supports,
the program type should be Comprehensive MCO + MLTSS.
Comprehensive MCO
When certain benefits, such as behavioral health, dental, or transportation, are
carved out of the comprehensive MCO program and covered through a limited
benefit program (i.e. a Prepaid Inpatient Health Plan or Prepaid Ambulatory
Health Plan), enrollees in such limited benefit plans should be reported in
separate programs of the appropriate type (e.g., BHO (PIHP and/or PAHP),
Dental PAHP, or Non-Emergency Medical Transportation, or an MLTSS-only
program when only LTSS and no other services are covered.
Individual beneficiaries can be enrolled in only one comprehensive MCO
program (either a comprehensive MCO or a comprehensive MCO+MLTSS) as
of the July 1 point in time.
Comprehensive MCO
+ MLTSS
Comprehensive Managed Care Organization + Managed Long-Term Services
and Supports: A program in which plans cover comprehensive acute and
outpatient benefits as defined above, where the same plan also covers longterm services and supports (LTSS).
Individual beneficiaries can be enrolled in only one comprehensive MCO
program (either a comprehensive MCO or a comprehensive MCO+MLTSS).
BHO Only (PIHP
and/or PAHP)
Behavior Health Organizations Only (Prepaid Inpatient Health Plan and/or
Prepaid Ambulatory Health Plan): A program specializing in behavioral health
(mental health and/or substance use disorder) services. Services are covered
on a prepaid basis.
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Managed Care
Program Type
Definition
Dental only (PAHP)
A Prepaid Ambulatory Health Program (PAHP) that only provides dental
services.
MLTSS Only
Managed Long Term Services and Supports Only: A program only covering
long term services and supports.
Other PHP
Other Prepaid Health Plan: A program covering a limited set of services
through PIHPs or PAHPs not otherwise included above. Examples include
disease management and pharmacy benefits.
PACE
Programs of All-Inclusive Care for the Elderly: A program that provides
prepaid, capitated comprehensive medical and social services in an adult day
health center, supplemented by in-home and referral services according to a
participant’s needs. To qualify, individuals must: (1) be 55 years of age or
older, (2) meet a nursing home level of care, and (3) live in a PACE
organizationservice area.
PCCM
Primary Care Case Management: A managed care arrangement in which
primary care providers contract with the state to provide a core set of case
management services to the enrollees assigned to them and to serve as the
enrollees’ home for medical care, in exchange for a monthly case management
fee. All other services are reimbursed on a FFS basis. Primary Care Providers
(PCPs) can include primary care physicians, clinics, group practices and nurse
practitioners, among others. In general, we would only expect case
management and physician services to be covered under capitation for PCCM
programs.
PCCM entity
Primary Care Case Management entity: In addition to providing primary care
case management services for the State, a PCCM entity is an organization that
provides any of the following functions: (1) Provision of intensive telephonic
or face-to-face case management, including operation of a nurse triage advice
line; (2) Development of enrollee care plans; (3) Execution of contracts with
and/or oversight responsibilities for the activities of FFS providers in the FFS
program; (4) Provision of payments to FFS providers on behalf of the State;
(5) Provision of enrollee outreach and education activities; (6) Operation of a
customer service call center; (7) Review of provider claims, utilization and
practice patterns to conduct provider profiling and/or practice improvement;
(8) Implementation of quality improvement activities including administering
enrollee satisfaction surveys or collecting data necessary for performance
measurement of providers; (9) Coordination with behavioral health
systems/providers; and/or (10) Coordination with long-term services and
supports systems/ providers.
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Managed Care
Program Type
Non-Emergency
Medical
Transportation
(NEMT)
Definition
A program that covers transportation to and from medically necessary health
care services in which these services are paid for on a per capita basis (the state
pays the transportation broker based on the number of people served, not the
amount of service or trips that each individual receives). Do not report
transportation programs in which individual trips are reimbursed on a FFS basis.
MANAGED CARE PLAN CROSSWALK
The table below provides a crosswalk for plan types to program types.
Managed Care Plan Type
Comprehensive MCO
Traditional PCCM Provider
Enhanced PCCM Provider
HIO
Medical-only PIHP (risk or non-risk/noncomprehensive/with inpatient hospital or institutional
services)
Medical-only PAHP (risk or non-risk/noncomprehensive/no inpatient hospital or institutional
services)
Long Term Care (LTC) PIHP
Mental Health (MH) PIHP
Mental Health (MH) PAHP
Substance Use Disorders (SUD) PIHP
Substance Use Disorders (SUD) PAHP
Mental Health (MH) and Substance Use Disorders
(SUD) PIHP
Mental Health (MH) and Substance Use Disorders
(SUD) PAHP
Dental PAHP
Transportation PAHP
Disease Management PAHP
PACE
Pharmacy PAHP
Accountable Care Organization
Health/Medical Home
•
•
•
•
•
Managed Care Program Type
Comprehensive MCO
Comprehensive MCO
+MLTSS (if benefits include
LTSS)
PCCM
PCCM
Comprehensive MCO
•
Other PHP
•
Other PHP
•
•
•
•
•
MLTSS Only
BHO (PIHP and/or PAHP)
BHO (PIHP and/or PAHP)
BHO (PIHP and/or PAHP)
BHO (PIHP and/or PAHP)
•
BHO (PIHP and/or PAHP)
•
BHO (PIHP and/or PAHP)
•
•
•
•
•
•
•
•
•
Dental
NEMT
Other PHP
PACE
Other PHP
Comprehensive MCO
Other PHP
PCCM
PCCM
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Integrated Care For Dual Eligibles
•
•
Comprehensive MCO + MLTSS,
MLTSS Only
(if benefits cover LTSS)
Unknown – it is not yet known how PCCM
entities will be reported in T-MSIS.
•
PCCM entity
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APPENDIX B: DRUG NAMES
Abacavir/Dolutegravir/Lamivudi
Accolate
Accupril
Acetaminophen
Acitretin
Acyclovir
Adalimumab
Aflibercept
Albuterol
Albuterol Sulfate/Ipratropium Bromide
Alendronate Sodium
Allopurinol
Alprazolam
Ambrisentan
Amiodarone Hydrochloride
Amitriptyline
Amlodipine
Amlodipine Besylate/Benazepril Hydrochloride
Amoxicillin
Amoxicillin/Potassium Clav
Amoxicillin; Clavulanate Potassium
Amphetamine
Androgens
Antihemophilic Factors
Anti-Inhibitor Coagulant Comp.
Apixaban
Apraclonidine
Argatroban
Aricept
Aripiprazole
Asenapine Maleate
Aspirin
Atazanavir
Atenolol
Atomoxetine
Atorvastatin
Azithromycin
Bacitracin/Neomycin/ Polymyxin B
Baclofen
Beclomethasone
Benazepril Hydrochloride
Benzonatate
Benztropine Mesylate
Bevacizumab
Brexipiprazole
Brimonidine Tartrate
Budesonide
Budesonide/ Formoterol
Buprenorphine
Buprenorphine Hcl/Naloxone Hcl
Bupropion
Buspirone Hydrochloride
Canagliflozin
Carbamazepine
Carbidopa/ Levodopa
Carisoprodol
Carvedilol
Celecoxib
Cephalexin
Cetirizine
Chlorthalidone
Cholecalciferol
Cinacalcet Hcl
Ciprofloxacin
Citalopram
Clindamycin
Clobazam
Clobetasol Propionate
Clonazepam
Clonidine
Clopidogrel Bisulfate
Coagulation Factors
Contraceptives
Corticotropin
Cyanocobalamin
Cyclobenzaprine
Cyclosporine
Darbepoetin Alfa In Polysorbat
Darunavir Ethanolate
Darunavir/Cobicistat
Deferasirox
Deferoxamine
Deserasirox
Desogestrel/ Ethinyl Estradiol
Dexlansoprazole
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Dexmethylphenidate
Dextroamphetamine/Amphetamine
Diazepam
Diclofenac
Dicyclomine Hydrochloride
Digoxin
Diltiazem Hydrochloride
Dimethyl Fumarate
Diphenhydramine
Divalproex Sodium
Docusate
Dolutegravir
Donepezil
Dornase
Dorzolamide Hydrochloride/Timolol Maleate
Doxazosin Mesylate
Doxycycline
Drospirenone/ Ethinyl Estradiol
Duloxetine
Eculizumab
Efavirenz/Emtricitabine/Tenofovir Disoproxil
Fumarate
Elbasvir/Grazoprevir
Elviteg/Cob/Emtri/Tenofo Disop
Elvitegravir/Cobicistat/Emtricitabine/Tenof
ovir Alafenamide
Emtricita/Rilpivirine/Tenof Df
Emtricitabine/Tenofovir Alafenamide
Enalapril Maleate
Enoxaparin Sodium
Entecavir
Epoetin Alfa
Ergocalciferol
Escitalopram
Esomeprazole
Estradiol
Etanercept
Estrogens
Everolimus
Exenatide
Ezetimibe
Famotidine
Fenofibrate
Fentanyl
Ferrous Sulfate
Filgrastim
Finasteride
Fingolimod
Fluconazole
Fluoxetine
Fluticasone
Fluticasone Propionate/ Salmeterol Xinafoate
Fluticasone/Salmeterol
Fluticasone/Vilanterol
Folic Acid
Furosemide
Gabapentin
Gemfibrozil
Glatiramer
Glimepiride
Glipizide
Glyburide
Guanfacine
Guanfacine Hcl Er
Haloperidol
Hctz
Heparin
Hydralazine Hydrochloride
Hydrochlorothiazide
Hydrochlorothiazide/ Lisinopril
Hydrochlorothiazide/ Losartan Potassium
Hydrochlorothiazide/ Triamterene
Hydrochlorothiazide/Valsartan
Hydrocodone
Hydrocodone /Apap
Hydrocortisone
Hydromorphone
Hydroxychloroquine Sulfate
Hydroxyprogesterone
Hydroxyzine
Ibuprofen
Imatinib Mesylate
Immune Globulins
Infliximab
Insulin Aspart
Insulin Detemir
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Insulin Glargine
Insulin Human
Insulin Lispro
Ipratropium
Ipratropium/Albuterol
Irbesartan
Isosorbide Mononitrate
Ketoconazole
Lacosamide
Lamotrigine
Lansoprazole
Latanoprost
Ledipasvir/Sofosbuvir
Lenalidomide
Leuprolide Acetate
Levalbuterol Hcl
Levetiracetam
Levocetirizine Dihydrochloride
Levofloxacin
Levothyroxine
Lidocaine
Linaclotide
Linagliptin
Lipase/Protease/Amylase
Liraglutide
Lisdexamfetamine
Lisinopril
Lithium
Loratadine
Lorazepam
Losartan
Lovastatin
Lumacaftor/Vacaftor
Lurasidone
Magnesium
Meclizine Hydrochloride
Meloxicam
Memantine Hydrochloride
Metformin
Metformin Hydrochloride/ Sitagliptin
Phosphate
Methocarbamol
Methotrexate
Methylcellulose (4000 Mpa.S)
Methylphenidate
Methylprednisolone
Metoprolol
Metronidazole
Mirtazapine
Mometasone
Mometasone/Formoterol
Montelukast
Morphine
Mupirocin
Naloxone
Naltrexone
Naltrexone Microspheres
Naproxen
Natalizumab
Nebivolol Hydrochloride
Nicotine Patch
Nifedipine
Nitrofurantoin
Nitroglycerin
Nivolumab
Nortriptyline Hydrochloride
Olanzapine
Olmesartan Medoxomil
Olopatadine
Omalizumab
Omega-3-Acid Ethyl Esters
Omeprazole
Ondansetron
Oseltamivir
Oxybutynin
Oxycodone
Oxycodone/Apap
Palbociclib
Paliperidone
Palivizumab
Pantoprazole Sodium
Paroxetine
Pegfilgrastim
Pioglitazone
Polyethylene Glycol 3350
Potassium
Pravastatin Sodium
Prednisolone
Prednisone
Pregabalin
Progesterone
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Promethazine
Promethazine Hydrochloride
Propranolol
Quetiapine
Raltegravir Potassium
Ramipril
Ranitidine
Ranitidine Hcl
Retinoids
Rifaximin
Risperidone
Risperidone Microspheres
Ritonavir
Rituximab
Rivaroxaban
Ropinirole Hydrochloride
Rosuvastatin
Rufinamide
Sertraline
Sertraline Hydrochloride
Sevelamer Hcl
Simvastatin
Sitagliptin
Sitagliptin Phos/Metformin Hcl
Sodium Chloride
Sofosbuvir/Velpatasvir
Solifenacin Succinate
Somatropin
Spironolactone
Sulfamethoxazole/ Trimethoprim
Sumatriptan
Tacrolimus
Tamsulosin Hydrochloride
Temazepam
Tenofovir Disoproxil Fumarate
Terazosin
Teriflunomide
Testosterone
Thyroid
Timolol
Tiotropium
Tizanidine
Topiramate
Tramadol
Trastuzumab
Trazodone
Treprostinil Sodium
Triamcinolone
Ustekinumab
Valacyclovir
Valsartan
Varenicline
Vedolizumab
Venlafaxine
Verapamil
Vitamins
Warfarin
Zolpidem
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APPENDIX C: DRUG CLASSES
Drug Class
Analgesics
Antacids
Antianxiety Drugs
Antiarrhythmics
Antibacterials
Antibiotics
Anticoagulants and Thrombolytics
Anticonvulsants
Antidepressants
Antidiarrheals
Antiemetics
Antifungals
Antihistamines
Antihypertensives
Anti-Inflammatories
Description
Drugs that relieve pain. There are two main types:
non-narcotic analgesics for mild pain, and
narcotic analgesics for severe pain.
Drugs that relieve indigestion and heartburn by
neutralizing stomach acid.
Drugs that suppress anxiety and relax muscles
(sometimes called anxiolytics, sedatives, or minor
tranquilizers).
Drugs used to control irregularities of heartbeat.
Drugs used to treat infections.
Drugs made from naturally occurring and
synthetic substances that combat bacterial
infection. Some antibiotics are effective only
against limited types of bacteria. Others, known as
broad spectrum antibiotics, are effective against a
wide range of bacteria.
Anticoagulants prevent blood from clotting.
Thrombolytics help dissolve and disperse blood
clots and may be prescribed for patients with
recent arterial or venous thrombosis.
Drugs that prevent epileptic seizures.
There are three main groups of mood-lifting
antidepressants: tricyclics, monoamine oxidase
inhibitors, and selective serotonin reuptake
inhibitors (SSRIs).
Drugs used for the relief of diarrhea. Two main
types of antidiarrheal preparations are simple
adsorbent substances and drugs that slow down
the contractions of the bowel muscles so that the
contents are propelled more slowly.
Drugs used to treat nausea and vomiting.
Drugs used to treat fungal infections, the most
common of which affect the hair, skin, nails, or
mucous membranes.
Drugs used primarily to counteract the effects of
histamine, one of the chemicals involved in
allergic reactions.
Drugs that lower blood pressure. The types of
antihypertensives currently marketed include
diuretics, beta-blockers, calcium channel blocker,
ACE (angiotensin- converting enzyme) inhibitors,
centrally acting antihypertensives and
sympatholytics.
Drugs used to reduce inflammation - the redness,
heat, swelling, and increased blood flow found in
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Drug Class
Antineoplastics
Antipsychotics
Antipyretics
Antivirals
Barbiturates
Beta-Blockers
Bronchodilators
Cold Cures
Corticosteroids
Cough Suppressants
Cytotoxics
Decongestants
Description
infections and in many chronic noninfective
diseases such as rheumatoid arthritis and gout.
Drugs used to treat cancer.
Drugs used to treat symptoms of severe
psychiatric disorders. These drugs are sometimes
called major tranquilizers.
Drugs that reduce fever.
Drugs used to treat viral infections or to provide
temporary protection against infections such as
influenza.
See "sleeping drugs."
Beta-adrenergic blocking agents, or beta-blockers
for short, reduce the oxygen needs of the heart by
reducing heartbeat rate.
Drugs that open up the bronchial tubes within the
lungs when the tubes have become narrowed by
muscle spasm. Bronchodilators ease breathing in
diseases such as asthma.
Although there is no drug that can cure a cold, the
aches, pains, and fever that accompany a cold can
be relieved by aspirin or acetaminophen often
accompanied by a decongestant, antihistamine,
and sometimes caffeine.
These hormonal preparations are used primarily as
anti-inflammatories in arthritis or asthma or as
immunosuppressives, but they are also useful for
treating some malignancies or compensating for a
deficiency of natural hormones in disorders such
as Addison's disease.
Simple cough medicines, which contain
substances such as honey, glycerine, or menthol,
soothe throat irritation but do not actually
suppress coughing. They are most soothing when
taken as lozenges and dissolved in the mouth. As
liquids they are probably swallowed too quickly
to be effective. A few drugs are actually cough
suppressants. There are two groups of cough
suppressants: those that alter the consistency or
production of phlegm such as mucolytics and
expectorants; and those that suppress the coughing
reflex such as codeine (narcotic cough
suppressants), antihistamines, dextromethorphan
and isoproterenol (non-narcotic cough
suppressants).
Drugs that kill or damage cells. Cytotoxics are
used as antineoplastics (drugs used to treat cancer)
and also as immunosuppressives.
Drugs that reduce swelling of the mucous
membranes that line the nose by constricting
blood vessels, thus relieving nasal stuffiness.
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Drug Class
Diuretics
Expectorant
Hormones
Hypoglycemics (Oral)
Immunosuppressives
Laxatives
Muscle Relaxants
Sedatives
Sex Hormones (Female)
Description
Drugs that increase the quantity of urine produced
by the kidneys and passed out of the body, thus
ridding the body of excess fluid. Diuretics reduce
water logging of the tissues caused by fluid
retention in disorders of the heart, kidneys, and
liver. They are useful in treating mild cases of
high blood pressure.
A drug that stimulates the flow of saliva and
promotes coughing to eliminate phlegm from the
respiratory tract.
Chemicals produced naturally by the endocrine
glands (thyroid, adrenal, ovary, testis, pancreas,
parathyroid). In some disorders, for example,
diabetes mellitus, in which too little of a particular
hormone is produced, synthetic equivalents or
natural hormone extracts are prescribed to restore
the deficiency. Such treatment is known as
hormone replacement therapy.
Drugs that lower the level of glucose in the blood.
Oral hypoglycemic drugs are used in diabetes
mellitus if it cannot be controlled by diet alone,
but does require treatment with injections of
insulin.
Drugs that prevent or reduce the body's normal
reaction to invasion by disease or by foreign
tissues. Immunosuppressives are used to treat
autoimmune diseases (in which the body's
defenses work abnormally and attack its own
tissues) and to help prevent rejection of organ
transplants.
Drugs that increase the frequency and ease of
bowel movements, either by stimulating the bowel
wall (stimulant laxative), by increasing the bulk of
bowel contents (bulk laxative), or by lubricating
them (stool-softeners, or bowel movementsofteners). Laxatives may be taken by mouth or
directly into the lower bowel as suppositories or
enemas. If laxatives are taken regularly, the
bowels may ultimately become unable to work
properly without them.
Drugs that relieve muscle spasm in disorders such
as backache. Antianxiety drugs (minor
tranquilizers) that also have a muscle-relaxant
action are used most commonly.
Same as Antianxiety drugs.
There are two groups of these hormones
(estrogens and progesterone), which are
responsible for development of female secondary
sexual characteristics. Small quantities are also
produced in males. As drugs, female sex
hormones are used to treat menstrual and
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Drug Class
Sex Hormones (Male)
Sleeping Drugs
Tranquilizer
Vitamins
Other
Description
menopausal disorders and are also used as oral
contraceptives. Estrogens may be used to treat
cancer of the breast or prostate, progestins
(synthetic progesterone to treat endometriosis).
Androgenic hormones, of which the most
powerful is testosterone, are responsible for
development of male secondary sexual
characteristics. Small quantities are also produced
in females. As drugs, male sex hormones are
given to compensate for hormonal deficiency in
hypopituitarism or disorders of the testes. They
may be used to treat breast cancer in women, but
either synthetic derivatives called anabolic
steroids, which have less marked side- effects, or
specific anti-estrogens are often preferred.
Anabolic steroids also have a "body building"
effect that has led to their (usually nonsanctioned)
use in competitive sports, for both men and
women.
The two main groups of drugs that are used to
induce sleep are benzodiazepines and barbiturates.
All such drugs have a sedative effect in low doses
and are effective sleeping medications in higher
doses. Benzodiazepines drugs are used more
widely than barbiturates because they are safer,
the side-effects are less marked, and there is less
risk of eventual physical dependence.
This is a term commonly used to describe any
drug that has a calming or sedative effect.
However, the drugs that are sometimes called
minor tranquilizers should be called antianxiety
drugs, and the drugs that are sometimes called
major tranquilizers should be called
antipsychotics.
Chemicals essential in small quantities for good
health. Some vitamins are not manufactured by
the body, but adequate quantities are present in a
normal diet. People whose diets are inadequate or
who have digestive tract or liver disorders may
need to take supplementary vitamins.
Please specify.
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APPENDIX D: DENIAL CODES
ACCUMULATION REFILL TOO SOON
AGE
BRAND REQUEST
CLAIM REQUIRES AN APPROVED TREATMENT
AUTHORIZATION REQUEST (TAR)
CLAIM SUBMITTED DOES NOT MATCH PA
COMPLIANCE MONITORING/EARLY OR LATE REFILL
CUMULATIVE EARLY REFILL
DAILY DOSE EXCEEDED
DAYS SUPPLY
DRUG COVERED BY MEDICARE PART D
DRUG LIST INITIATIVE THRESHOLD
DRUG-DISEASEREPORTED PRECAUTION
DRUG-DRUG INTERACTION
DUPLICATE CLAIM
DUR REJECT ERROR
EARLY REFILL: OVERUSE PRECAUTION
ELIGIBILITY
EXCEEDS ALLOWABLE PLAN DAYS SUPPLY
FILLED AFTER COVERAGE TERMINATED
HIGH DOSE ALERT
M/I DAYS SUPPLY
M/I DIAGNOSIS CODE
M/I OTHER COVERAGE CODE
M/I PRESCRIBER
MD MUST CALL FOR A PRIOR AUTHORIZATION
MEMBER ENROLLED IN MANAGED CARE
MEMBERS BENEFITS PACKAGE DOES NOT INCLUDE
THIS MEDICATION
NDC NOT CONSISTENT WITH ANY BILLED
DIAGNOSIS
NDC NOT COVERED
NDC VS DIAGNOSIS RESTRICTION
NO REBATE
NON-COVERED AND NON-REBATE PRODUCTS
NON-MATCHED PRESCRIBER ID
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NON-PREFERRED DRUG
OVER UTILIZATION PRECAUTION
PATIENT IS NOT COVERED
PDL
PHARMACY MAINTENANCE SUPPLY REQUIRED FOR
DRUG
PLAN LIMITATIONS EXCEEDED
PRESCRIBER IS NOT COVERED
PRIOR AUTHORIZATION REQUIRED
PRODUCT/SERVICE NOT COVERED – PLAN/BENEFIT
EXCLUSION
PRODUR ALERT
PROVIDER NOT ENROLLED IN BENEFIT PLAN
BILL MEDICARE
QUANTITY DISPENSED EXCEEDS MAXIMUM
ALLOWED
REFILL EXCEEDS MAX. ALLOWABLE REFILLS
REFILL TOO SOON
REPORTED DISEASE
SERVICE NOT COVERED
SUBMIT BILL TO OTHER PROCESSOR OR PRIMARY
PAYOR
TAMPER PROOF PAD REQD
THERAPEUTIC DUPLICATION
UNDER UTILIZATION PRECAUTION
65
| File Type | application/pdf |
| File Title | PRA_MCO DUR Annual Report Survey_FFY_2020_Final |
| Author | Yolonda Williams |
| File Modified | 2020-07-15 |
| File Created | 2020-07-08 |