CMS-R-153 Abbreviated MCO Report

FFY 2020 MEDICAID DRUG UTILIZATION REVIEW ANNUAL ABBREVIATED REPORT

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 DUR programs; a summary
of the interventions used in retrospective DUR (RetroDUR) and an assessment of the education program;
and an assessment of the DUR program’s impact on quality of care. If medication is associated with a
prescription and the medication is dispensed, the expectation is prospective and retrospective requirements
are to be applicable. If medications are clinically administered, the expectation is only for retrospective
reviews. If traditional drug benefits are not part of the benefit package, then the MCO would not be required
to have a prospective program unless they review a Healthcare Common Procedure Coding System
(HCPCS) request for clinical appropriateness and have a DUR component engrained in that process. It is
expected that if the drug benefit is handled separately there are file transfers of the drug claim file so MCOs
can coordinate that aspect of the 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 and is an abbreviated version of the
MCO survey for states that have pharmacy benefits covered through the FFS program, but MCOs still have
some portion of benefits for covered outpatient drugs.
Answering the attached questions and returning the requested materials as attachments to the report will
constitute compliance with the above-mentioned statutory and regulatory requirements. If you have any
questions regarding the DUR Annual Report, please contact your state’s Medicaid Pharmacy Program.
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
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 C4-26-05, Baltimore, Maryland 212441850.

FFY 2020 MEDICAID DRUG UTILIZATION REVIEW ANNUAL ABBREVIATED REPORT

MEDICAID MANAGED CARE ORGANIZATION (MCO)
CLINICALLY ADMINISTERED DRUGS
COORDINATED WITH A PHARMACY CARVE-OUT
MEDICAID DRUG UTILIZATION REVIEW ANNUAL ABBREVIATED REPORT
FEDERAL FISCAL YEAR 2020
I. DEMOGRAPHIC INFORMATION
State Abbreviation:
MCO Name:
Please Note: Name above must match name entered in Medicaid Drug Program (MDP) DUR system

Medicaid MCO Information
Identify the MCO person responsible for DUR Annual Report Preparation.
First Name:
Last Name:
Email Address:
Area Code/Phone Number:

1. On average, how many Medicaid beneficiaries are enrolled monthly in your MCO for this
Federal Fiscal Year?
___________Beneficiaries
2. Are all Section1927(g) of the Social Security Act (the Act) covered outpatient drugs (CODs)
included in Fee-for-Service (FFS) pharmacy benefits (CODs include drugs dispensed in a
pharmacy, administered in a doctor’s office, outpatient hospital or clinic. Drugs reimbursed
at bundled/global rate are not considered outpatient drugs)?

 No
 Yes, FFS covers all 1927 covered outpatient drugs.

--------------------If Yes, completion of the remaining survey is voluntary--------------------------

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3. Please list what CODs are included in the benefits by your MCO (i.e. physician administered
drugs (PAD), medication assisted treatment (MAT) at outpatient treatment programs (OTPs),
and outpatient hospital drugs)?

 Drugs administered in a clinic or physician’s office
 Drugs administered during an outpatient hospital stay
 Emergency Departments
 Outpatient Treatment Programs
 Other, please explain

4. What practices and policies do you have in place to share information between providers?
NOTE: It is expected that if the drug benefit is handled separately there are file transfers of
the drug claim file so MCOs can coordinate that aspect of the care.
Please explain.

a. Please explain the process for coordination of clinical outcomes between medical
providers and pharmacy?

b. How is quality of care for prescriptions ensured? Please explain

5. Does your MCO have a documented process (i.e. prior authorization) in place, so that the
Medicaid beneficiary or the Medicaid beneficiary’s prescriber may access any COD covered
under your benefit plan when medically necessary?
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 Yes, what is the preauthorization (PA) process?

 No, please explain why there is not a process for the beneficiary to access a COD
when it is medically necessary.

II. RETROSPECTIVE DUR (RetroDUR)
1. Who reviews and approves the RetroDUR criteria?

 MCO DUR Board
 MCO P&T Board
 MCO pharmacy manager
 State pharmacy director
 Combination of medical and pharmacy directors
 State DUR Board
 Outside entities
 Other, please explain.

2. Summary 1 – RetroDUR Educational Outreach Summary
Summary 1: Retrospective DUR Educational Outreach is a summary report on RetroDUR
profile screening and educational opportunities during the fiscal year reported. The 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.

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_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

III. PHYSICIAN ADMINISTERED DRUGS
1. 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 claims processing system been designed to evaluate the drug
data supplied by the state into your RetroDUR criteria or PA reviews?

 Yes
 No
If “No”, do you have a plan to include this information in your DUR criteria in the
future?

 Yes
 No

IV. 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 FWA of controlled
drugs by beneficiaries?

 Yes
 No
If “Yes”, what actions does this process initiate? Check all that apply:

o Deny claims and require prior authorization
o Refer to Lock-In Program
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o Refer to Program Integrity Unit (PIU)/Surveillance Utilization Review
(SUR) Unit

o Refer to Office of Inspector General (OIG)
o Other, please explain.

2. Do you have a coordinated process in place with the state, such as 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 is used to identify beneficiaries with potential FWA of controlled
substances? Check all that apply.

o Number of controlled substances (CS)
o Different prescribers of CS
o Multiple pharmacies
o Number days’ supply of CS
o Exclusivity of short acting opioids
o Multiple ER visits
o Prescription Drug Monitoring Program (PDMP) data
o Same FFS state criteria is applied
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o Other, please explain.

b. Do you have the capability to restrict the beneficiary to a prescriber only?

 Yes
 No
 N/A
3. Do you have a documented process in place that identifies possible FWA of controlled
drugs by prescribers?

 Yes
 No
If “No”, please explain.

If “Yes”, what actions does this process initiate? Check all that apply.

 Deny claims written by this prescriber
 Refer to Program Integrity Unit (PIU)/Surveillance Utilization Review
(SUR) Unit

 Refer to the appropriate Medical Board
 Other, please explain.

4. Do you have a documented process in place that identifies and/or prevents potential
FWA of non-controlled drugs by beneficiaries?
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 Yes, please explain your program for FWA of non-controlled substances.

 No, please explain.

B. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
1. Do you require prescribers (in your provider agreement with your MCO) to access the
PDMP patient history before prescribing controlled substances?

 Yes, please explain how your program applies this information to control FWA.

 No, the state does not have a PDMP.
 No, please explain.

2. Does your MCO have the ability to query the state’s PDMP database?

 Yes, we receive PDMP data
 Daily
 Weekly
 Monthly
 Other ______________
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 Yes, we have access to the database
 No
If “Yes”, are there barriers that hinder your MCO from fully accessing the PDMP
that prevent the program from being utilized the way it was intended to be to curb
FWA?

 Yes, please explain the barriers that exist.

 No
3. Does your MCO have access to Border States’ PDMP information?
 Yes

 No
C. OPIOIDS
1. Do you coordinate with the entity that provides the drug benefits to monitor opioid
prescriptions (duplicate therapy, early refills, quantity limits, etc.)?

 Yes
 No
Please explain above response.

2. Do you have comprehensive retrospective claims review process to monitor opioid
prescriptions exceeding state defined limitations?

 Yes, please explain in detail the scope and nature of these retrospective reviews.

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 No, please explain.

3. Do you coordinate with the entity that provides the drug benefits to monitor opioids and
benzodiazepines being used concurrently?

 Yes, retrospective claim reviews
 Yes, educational programs
 Yes, titration programs
 Yes, peer to peer assistance
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).

o No, please explain.

4. Do you coordinate with the entity that provides the drug benefits to monitor opioids and
sedatives being used concurrently?

 Yes, retrospective reviews
 Yes, educational programs
 Yes, titration programs
 Yes, peer to peer assistance
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Please explain response above and detail the scope and nature of reviews
and edits.

o No, please explain.

5. Do you coordinate with the entity that provides the drug benefits to monitor opioids and
antipsychotics being used concurrently?

 Yes, retrospective reviews
 Yes, educational programs
 Yes, titration programs
 Yes, peer to peer assistance

Please explain response above and detail the scope and nature of reviews
and edits.

o No, please explain.

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6.

Do you have safety edits or perform RetroDUR activity and/or provider education in
regard to beneficiaries with a diagnosis or history of opioid use disorder (OUD) or
opioid poisoning diagnosis?

 Yes, POS edits
 Yes, retrospective reviews and/or provider education
 No
If the answer to question 6 is “Yes, retrospective reviews 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 reviews RetroDUR and/or provider
education reviews performed.

If the answer to question 6 is “No”, do you plan on implementing a RetroDUR
activity and/or provider education in regard to beneficiaries with a diagnosis or
history of OUD or opioid poisoning in the future?

 Yes, when do you plan on implementing?

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 No, please explain.

7. Does your 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.

D. MORPHINE MILLIGRAM EQUIVALENT (MME) DAILY DOSE
1. Do you coordinate with the entity that provides the drug benefits to monitor total daily
dose (MME) of opioid prescriptions dispensed?

 Yes
 No
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Please explain above response.

E. OPIOID USE DISORDER (OUD) TREATMENT
1. Do you coordinate with the entity that provides the drug benefits to monitor and manage
appropriate use of naloxone to persons at risk of overdoes?

 Yes
 No
Please explain above response.

F. OPIOID TREAT PROGRAMS (OTP)
1. Does your program cover medications used for OUD through OTPs?

 Yes
 No
If yes, please explain how MAT drugs are billed through OTPs.

G. ANTIPSYCHOTICS /STIMULANTS
ANTIPSYCHOTICS

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1. Do you coordinate with the entity that provides the drug benefits 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. Please briefly explain the specifics of your antipsychotic monitoring
program(s).

If you do not have a documented antipsychotic 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 antipsychotic drugs in children.

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STIMULANTS
2. Do you coordinate with the entity that provides the drug benefits 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. Please briefly explain the specifics of your documented stimulant
monitoring program(s).

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.

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V. INNOVATIVE PRACTICES
Summary 2 – 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 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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