CMS-R-153 MCO Medicaid Annual Report

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) 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. 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, 2020 to September 30, 2021 and is due for submission to
CMS Central Office by no later than June 30, 2022. 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: Please download a copy of the survey to your desktop before starting or distributing
the survey. Adobe Acrobat Reader must be used to edit the survey. The MCO survey cannot be edited
within a browser window. Adobe Acrobat Reader must be used to edit the survey. The MCO survey cannot
be edited within a browser
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).
Individual managed care plan’s survey results will be published online and will be publicly available similar
to the Fee-for-Service (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:

 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 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 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

I. DEMOGRAPHIC INFORMATION
State Abbreviation:
MCO Name:
Please note: Name above must match name entered in Medicaid Drug Programs (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

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

II.

PROSPECTIVE DUR (ProDUR)
1. Indicate the type of your pharmacy point of service (POS) vendor and identify by name.

 State-operated
 Contractor
 Other organization
If “Contractor” or “Other organization”, please identify by name your pharmacy
POS vendor.

If “Other”, please specify.

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. Check all that apply:

 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

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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.

4. Does your MCO receive periodic reports providing individual pharmacy providers DUR alert
override activity in summary and/or in detail?

 Yes
a) How often does your MCO receive reports? Check all that apply:

 Monthly
 Quarterly
 Annually
 Ad hoc (on request)
 Other, please explain.

b) Does your MCO follow
with interventions?

up with those providers who routinely override

 Yes
By what method does your MCO follow up? Check all that apply:

 Contact Pharmacy
 Refer to Program Integrity (PI) for Review
 Other, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 No
 No, please explain.

5. Early Refill
a) At what percent threshold does your MCO set your system to edit?
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 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

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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
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:

 Lost/stolen RX
 Vacation
 Overrides are only allowed
 Other, please explain.

by a pharmacist through a PA

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

7. Does your system have an accumulation edit to prevent patients from continuously filling
prescriptions early?

 Yes
 No
If “Yes”, please explain your edits.

If “No”, does your MCO plan to implement this edit?

 Yes
 No
8. Does your 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
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.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 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.

b) Does your program provide for the dispensing of at least a 72-hour supply of a
covered outpatient drug (CODs) in an emergency situation?

 Yes
Check all that apply:

 Real time automated process
 Retrospective PA
 Other process, please explain.

 No, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

Table 1: Top Drug Claims Data Reviewed by the DUR Board
NOTE: if an entry is not included in the drop-down box list, please select ‘other’ at end of the list and enter a free form response in the box 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

Column 6

% 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

Column 7

Drugs by Claim Count % of
Total Claims
(From data in Column 6,
determine the % of total claims)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

III. 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. Identify the vendor, by name and type that performed your RetroDUR activities during the
time period covered by this report.

 Company

If “Other”, please identify by name and type.

 Academic Institution, please identify by name and type.

 Other Institution, please identify by name and type.

a) Is the RetroDUR vendor the developer/supplier of your retrospective DUR criteria?

 Yes, please explain.

 No, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

b) Does your MCO customize your RetroDUR vendor criteria?

 Yes
 No
 Ad hoc based on state-specific needs
3. Who reviews and approves your MCO 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 does your MCO perform retrospective reviews that involves communication
of client specific information to healthcare practitioners (through messaging, fax, or
mail)? Check all that apply:

 Monthly

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 Bi-monthly
 Quarterly
 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:
Summary 1: RetroDUR Educational Outreach
RetroDUR Educational Outreach Summary should be a year-end summary report on
retrospective screening and educational interventions. 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.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

IV. DUR BOARD ACTIVITY
1. Does your MCO utilize the same DUR Board as the state FFS Medicaid program or does
your MCO have its own DUR Board?

 Same DUR Board as FFS agency
 MCO has its own DUR Board
 Other, please explain.

2. Does your MCO have a Medication Therapy Management (MTM) Program?

 Yes
 No
Summary 2: DUR Board Activities
DUR Board Activities Summary should include a brief descriptive report on DUR activities
during the fiscal year reported. This summary should:
•

Indicate the number of DUR Board meetings held

•

List additions/deletions to DUR Board approved criteria
a) For ProDUR, list problem type/drug combinations added or deleted
b) 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)

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DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

V. 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”, does your MCO have a plan to include this information in your DUR criteria in
the future?

 Yes
 No
2. RetroDUR?

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

 Yes
 No

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

VI. GENERIC POLICY AND UTILIZATION DATA
Summary 3: Generic Drug Substitution Policies
Generic Drug Substitution Policies should summarize factors that could affect your generic
utilization percentage. In describing these factors, please explain any formulary management
or cost containment measures, preferred drug list (PDL) policies, educational initiatives,
technology or promotional factors, or other state specific factors that affects your generic
utilization rate.

1. 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

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

Complete Table 2: Generic Drug Utilization Data using the following Computation Instructions.
Computation Instructions
KEY
Single Source (S) – Drugs having an FDA New Drug Application (NDA), and there
are no generic alternatives available on the market.
Non-Innovator Multiple-Source (N) – Drugs that have an FDA Abbreviated New
Drug Application (ANDA), and generic alternatives exist on the market.
Innovator Multiple-Source (I) – Drugs which have an NDA and no longer have
patent exclusivity.
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 “National Drug Code and Drug Category
file [ZIP],” then open the Medicaid Drug Product File 4 th Qtr. Excel file).

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

Please provide the following utilization data for this DUR reporting period for all covered
outpatient drugs paid. Exclude Third Party Liability (TPL).
Table 2: Generic Drug Utilization Data
Single Source (S)
Drugs

Non-Innovator (N)
Drugs

Innovator MultiSource (I) Drugs

Total Number of Claims
Total Reimbursement
Amount Less Co-Pay

2. Indicate the generic utilization percentage for all CODs paid during this reporting period,
using the computation instructions in Table 2: Generic Utilization Drug Data.
Number of Generic Claims:

__________________

Total Number of Claims:

__________________

Generic Utilization Percentage:

__________________

3. How many multi-source drugs have the innovator as the preferred drug product based on net
pricing (brand preferred over generic)?
__________________
4. Indicate the percentage dollars paid for generic CODs in relation to all COD claims paid
during this reporting period using the computation instructions in Table 2: Generic Drug
Utilization Drug Data.
Generic Dollars:

__________________

Total Dollars:

__________________

Generic Expenditure Percentage: __________________
5. Does your MCO have any policies related to Biosimilars? Please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

VII. FRAUD, WASTE AND ABUSE DETECTION (FWA)
A. LOCK-IN OR PATIENT REVIEW AND RESTRICTION PROGRAMS

1. Does your MCO 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
 Require prior authorization (PA)
 Refer to Lock-In Program
 Refer to Program Integrity Unit (PIU) and/or Surveillance Utilization Review (SUR)
Unit for audit/investigation

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

2. Does your MCO 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
Check All that apply:

 Number of controlled substances (CS)

candidates for Lock-in?

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 Different prescribers of CS
 Multiple pharmacies
 Days’ supply of CS
 Exclusivity of short acting opioids
 Multiple emergency room (ER) visits
 Prescription Drug Monitoring Program (PDMP) data
 Same FFS state criteria is applied
 Other, please explain.

b) Does your MCO 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) What is the usual Lock-in time period?

 12 months
 18 months
 24 months
 As determined by the state/MCO on a case by case basis
 Lock-in time period is based on number of offenses

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 Other, please explain.

d) On average, what percentage of your Medicaid MCO population is in Lock-in status
annually?
%
e) Please provide an estimate of the savings attributed to the Lock-In Program for the
fiscal year under review.
$
3. Does your MCO have a documented process in place that identifies potential 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 (PIU) and/or Surveillance Utilization Review (SUR)
Unit for audit/investigation

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

 No, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

4. Does your MCO 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 (PIU) and/ or Surveillance Utilization Review (SUR)
Unit for audit/investigation

 Refer to the Board of Pharmacy
 Other, please explain.

 No, please explain.

5. Does your MCO have a documented process in place that identifies and/or prevents potential
fraud or abuse of non-controlled drugs by beneficiaries, prescribers, and pharmacy
providers?

 Yes, please explain your program for FWA of non-controlled substances.

 No, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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 compliant with provisions outlined in Section 5042 and CMS
reporting, beginning in 2023..
1. Does your MCO have the ability to query the state’s PDMP database?

 Yes, receive PDMP data
Please indicate how often:

 Daily
 Weekly
 Monthly
 Other, please specify:
 Yes, have access to the database
Check all that apply:

 Can query by client
 Can query by prescriber
 Can query by dispensing entity
 No, please explain.

If “Yes”, please continue.
a) Please explain how your MCO program applies this information to control FWA
of controlled substances.

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DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

b) Does your MCO have access to Border States’ PDMP information?

 Yes
 No
c) Does your MCO also have PDMP data integrated into your POS edits?

 Yes
 No
2. Does your MCO or the professional board require prescribers (in your provider agreement)
to access the PDMP patient history before prescribing controlled substances?

 Yes
 No, please explain.

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

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

c) If a provider is not able to conduct PDMP checks, does your MCO require the
prescriber to document a good faith effort, including the reasons why the provider
was not able to conduct the check?

 Yes
Does your MCO require the provider to submit, upon request, documentation to
the MCO?

 Yes
 No, please explain.

 No, please explain.

3. Does your MCO require pharmacists to check the PDMP prior to dispending?

 Yes
 No, please explain.

If “Yes,” are there protocols involved in checking the PDMP?



Yes, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY



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 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 (i.e. lag time in prescription data being
submitted, prescribers not accessing, pharmacists unable to view prescription
history before filling script).

 No
5. (Optional) 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:
%

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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

Please complete Tables 3, 4, 5 and 6 below. Specify the controlled substances prescribed
based on prescriptions dispensed (by generic ingredient(s)) and within each population
during this FFY reporting period.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

Table 3: Top Opioid Controlled Substances by Population.

Population

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
Cate gories

Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Numbe r of
Numbe r of Unique
Pe rce ntage of Unique
Top 3 O pioid Controlled
Numbe r of Unique
Pe rce ntage of Unique
Be ne ficiaries Within Be ne ficiaries Within Each Be ne ficiaries Within Each Age
Substances Re ceive d
Be ne ficiaries Within Each Age Be ne ficiaries Within Each Age
Each Age Group Age Group Re ce iving an
Group Re ce iving an O pioid
Within Each Age Group Group Re ce iving the O pioid
Group Re ce iving the Top 3
O pioid Controlled
Controlled Substances in the 12 (Ge ne ric Ingredient) in the
Controlled Substance
O pioid Controlled Substance
Substance in the 12 Month
Month Re porting Pe riod
12 Month Re porting Pe riod (Spe cified in Column 4) in the (Spe cified in Column 4) in the
Re porting Period
12 Month Re porting Pe riod 12 Month Re porting Pe riod

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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

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
Cate gories

Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Numbe r of
Numbe r of Unique
Pe rce ntage of Unique
Top 3
Numbe r of Unique Beneficiaries
Pe rce ntage of Unique Beneficiaries
Be ne ficiaries
Be ne ficiaries Within Be ne ficiaries Within Each Se dative /Benzodiazepine Within Each Age Group Re ceiving Within Each Age Group Re ceiving the
Within Each Age Each Age Re ce iving a Age Group Re ce iving a Re ce ive d Within Each Age
the Se dative/Benzodiazepine
Top 3 Se dative/Benzodiazepine
Group
Se dative /
Se dative /Benzodiazepine
Group (Ge neric
(Spe cified in Column 4) in the 12
(Spe cified in Column 4) in the 12
Be nz odiazepine in the
in the 12 Month
Ingre die nt) in the 12
Month Re porting Pe riod
Month Re porting Pe riod
12 Month Re porting
Re porting Period
Month Re porting Pe riod
Pe riod

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

Table 5: Top Stimulant/ADHD Controlled Substances by Population-When listing the controlled substances in different drug categories,
please consider long and short acting ADHD medications to be in the same category.

Population

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
Cate gories

Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Numbe r of
Numbe r of Unique
Pe rce ntage of Unique
Top 3 Stimulant/ADHD
Numbe r of Unique Beneficiaries
Pe rce ntage of Unique Beneficiaries
Be ne ficiaries
Be ne ficiaries Within Be ne ficiaries within Each Me dication Within Each Within Each Age Group Re ceiving a Within Each Age Group Re ceiving the
Within Each Age Each Age Re ce iving a Age Group Re ce iving a
Age Group (Ge neric
Stimulant/ADHD Me dication
Top 3 Stimulant/ADHD Me dication
Group
Stimulant/ ADHD
Stimulant/ADHD
Ingre die nt) in the 12
(Spe cified in Column 4) in the 12
(Spe cified in Column 4) in the 12
Me dication in the 12
Me dication in the 12
Month Re porting Pe riod
Month Re porting Pe riod
Month Re porting Pe riod
Month Re porting
Month Re porting Pe riod
Pe riod

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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. Please note, Column
2 and Column 4 are requesting an average monthly value based on the 12-month reporting period.

Population

Column 1
Column 2
Column 3
Column 4
Column 5
Total Numbe r of
Numbe r of Unique
Pe rce ntage of Age
Numbe r of Unique
Pe rce ntage of Age
Be ne ficiaries within Each Be ne ficiaries in Each Age Group Re ce iving Be ne ficiaries in Each Age Group Re ce iving
Age Group
Group Re ce iving 2 or more
2 or more
Group Re ce iving 3 or more
3 or more
Controlled Substances in
Controlled
Controlled Substances in
Controlled
Diffe re nt Drug Categories
Substances
Diffe re nt Drug Categories Substances pe r
pe r Month Ave rage d for Ave rage d for the pe r Month Ave rage d for Month Ave rage d
the 12 Month Re porting
12 Month
the 12 Month Re porting for the 12 Month
Pe riod
Re porting Period
Pe riod
Re porting Period

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
Cate gories

i)

If there is additional information you want to provide for the previous 12-month
reporting period, please explain below, or specify N/A if not applicable.

ii) If any of the information requested is not being reported above, please explain
below, or specify N/A if not applicable.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

6. In this reporting period, have there been any data or privacy breaches of the PDMP or PDMP
data?

 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.

 No

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

C. OPIOIDS
1. Does your MCO currently have a POS edit in place to limit the days supply dispensed of an
initial opioid prescription for opioid naïve patients?

 Yes, for all opioids
 Yes, for some opioids
 No
Please explain response above.

If “No”, skip to question 1.b.

a) What is your maximum number of days allowed for an initial opioid prescription for
an opioid naïve patient?
# of days
b) Does your MCO have POS edits in place to limit days supply of subsequent opioid
prescriptions ? If yes, please indicate your days supply limit ?



24-day supply



30-day supply




34-day supply



Other________



No

90-day supply

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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c. Please explain above response, or add N/A if not applicable.

2. Does your MCO have POS edits in place to limit the quantity dispensed of short-acting (SA)
opioids?

 Yes, please specify limit. _____# of units
 No, please explain.

 Other, please explain.

3. Does your MCO currently have POS edits in place to limit the quantity dispensed of
long-acting (LA) opioids?

 Yes, please specify limit. _____# of units
 No, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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 Other, please explain.

4. Does your MCO have measures other than restricted quantities and days’ supply in place to
either monitor or manage the prescribing of opioids?

 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 are in place.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 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. Does your MCO 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. Does your MCO have POS edits to monitor early refills of opioid prescriptions dispensed?

 Yes, POS edits
 Yes, automated retrospective claims review process
 Yes, both POS edits and automated retrospective claims review process
 No
If any response is “Yes”, please explain scope and nature of reviews and edits.

If “No”, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

7. Does your MCO have comprehensive automated retrospective claim reviews to monitor
opioid prescriptions exceeding state limitations (early refills, duplicate fills, quantity limits
and days’ supply)?

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

 No, please explain.

8. Does your MCO currently have POS edits in place or automated retrospective claim reviews
to monitor opioids and benzodiazepines being used concurrently?

 Yes, POS edits only
 Yes, automated retrospective claim reviews only
 Yes, both POS edits and automated retrospective claims review process
Please explain the above response and detail the scope and nature of these reviews and/or
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).

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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 No, please explain.

9. Does your MCO currently have POS edits in place or automated retrospective claim reviews
to monitor opioids and sedatives 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/or
edits.

 No, please explain.

10. Does your MCO currently have POS edits in place or an automated retrospective claims
review process to monitor opioids and antipsychotics being used concurrently?

 Yes, POS edits
 Yes, automated retrospective claims review process

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 Yes, both POS edits and automated retrospective claims review process
Please explain the above response and detail the scope and nature of these reviews and/or
edits.

 No, please explain.

11. Does your MCO have POS safety edits or perform automated respective claims review
and/or provider education in regard to beneficiaries with a diagnosis or history of opioid use
disorder (OUD) or opioid poisoning diagnosis (check all that apply)?

 Yes, POS edits
 Yes, automated retrospective claims review
 Yes, provider education
 No
If “No”, skip to question 11.c.
If “Yes, automated retrospective claims review and/or provider education”, please
continue with questions 11.a and 11.b.
a) Please indicate how often:

 Monthly
 Quarterly
 Semi-Annually
 Annually
 Ad hoc

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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 Other, please specify.

b) Please explain the nature and scope of edits, reviews and/or provider education
reviews performed.

If “No”, please continue.
c) Does your MCO plan on implementing POS edits, automated retrospective claim
reviews and/or provider education in regard to beneficiaries with a diagnosis or
history of OUD or opioid poisoning in the future?

 Yes, when does your MCO plan on implementing?

 No, please explain.

12. Does your MCO program develop and provide prescribers with pain management or opioid
prescribing guidelines?

 Yes, please check all that apply:

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 Your prescribers are referred to the Center for Disease Control (CDC) Guideline for
Prescribing Opioids for Chronic Pain

 Other guidelines, please identify.

 No, please explain why no guidelines are offered.

13. Does your MCO 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

14. Were there COVID-19 ramifications on edits and reviews on controlled substances during
the public health emergency?



Yes, please explain.



No

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

D. MORPHINE MILLIGRAM EQUIVALENT (MME) DAILY DOSE
1. Have you set recommended maximum MME daily dose measures?

 Yes
 No, please explain the measure or program you utilize.

If “Yes”, please continue.
a) What is your maximum MME daily dose limit in milligrams?

 Less than 50 MME, please specify.

mg per day

 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

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?).

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

2. Does your MCO 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”, does your MCO require PA if the MME limit is exceeded?

 Yes
 No
3. Does your MCO have automated retrospective claims review to monitor the MME total daily
dose of opioid prescriptions dispensed?

 Yes, please explain.

 No, please explain.

4. Does your MCO provide information to your prescribers on how to calculate the morphine
equivalent daily dosage or does your MCO provide a calculator developed elsewhere?

 Yes
 No
If “Yes,” please continue.
a) Please name the developer of the calculator.

 CDC
 Academic Institution
 Other, please specify.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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b) How is the information disseminated? Check all that apply:

 Website
 Provider notice
 Educational seminar
 Other, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

E. OPIOID USE DISORDER (OUD) TREATMENT
1. Does your MCO 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 MCO set total mg per day limits
buprenorphine/naloxone combination drugs?

on the use of buprenorphine

 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
 6 months

and

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 12 months
 24 months
 Other, please explain.

4. Does your MCO 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?

 No limit
 6 months
 12 months
 Other, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

5. Does your MCO have at least one buprenorphine/naloxone combination product available
without PA?

 Yes
 No
6. Does your MCO 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. Does your MCO have at least one naloxone opioid overdose product available without PA?

 Yes
 No

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

9. Does your MCO retrospectively monitor and manage appropriate use of naloxone to persons
at risk of overdose?

 Yes
 No, please explain.

10. Does your MCO allow pharmacists to dispense naloxone prescribed independently or by
collaborative practice agreements, or standing orders, or other predetermined protocols?

 Yes, please explain.

 No

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

F. OUTPATIENT TREATMENT PROGRAMS (OTP)
1. Does your MCO cover OTPs that provide 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 MCO cover buprenorphine or buprenorphine/naloxone for diagnoses of OUD as
part of a comprehensive MAT treatment plan through OTPs?

 Yes
 No, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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 substance use disorder (i.e. OTPs, Methadone
Clinics)?

 Yes
 No

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

G. PSYCHOTROPHIC MEDICATION
ANTIPSYCHOTICS
1. Does your MCO currently have restrictions in place to limit the quantity of antipsychotic
drugs?

 Yes
 No
Please explain restrictions or N/A.

2. Does your MCO 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 with questions 2.a, 2.b and 2.c.
a) Does your MCO either manage or monitor:

 Only children in foster care
 All children
 Other, please explain.

b) Does your MCO have edits in place to monitor (check all that apply):

 Child’s Age, please specify age limit: _____years

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 Dosage
 Indication
 Polypharmacy
 Other, please explain.

c) Please briefly explain the specifics of your documented antipsychotic monitorin g
program(s).

If “No,” please continue.
d) Does your MCO plan on implementing an antipsychotic monitoring program in the
future?

 Yes, please specify when you plan on implementing a program to monitor the
appropriate use of antipsychotic drugs in children.

 No, please explain why you will not be implementing a program to monitor the
appropriate use of antipsychotic drugs in children.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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STIMULANTS
3. Does your MCO currently have restrictions in place to limit the quantity of stimulant drugs?

 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 “No”, skip to question 4.d.
If “Yes”, please continue with questions 4.a, 4.b and 4.c.
a) Does your MCO 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, please specify age limit: ______ years
 Dosage
 Indication
 Polypharmacy
 Other, please explain.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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c) Please briefly explain the specifics of your documented stimulant monitorin g
program(s).

If “No”, please continue.
d) Does your MCO plan on implementing a stimulant monitoring program in the
future?

 Yes, please specify when you plan on implementing a program to monitor the
appropriate use of stimulant drugs in children.

 No, please explain why you will not be implementing a program to monitor the
appropriate use of stimulant drugs in children.

ANTIDEPRESSANTS
5. Does your MCO have a documented program in place to either manage or monitor the
appropriate use of antidepressant drugs in children?




Yes
No

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

If “Yes,” please continue.
a. Does your MCO either manage or monitor:



Only children in foster care



All children



Other, please explain.

b. Does your MCO have edits in place to monitor (check all that apply):







Child’s age, please specify age limit: _______years
Dosage
Indication
Polypharmacy
Other, please explain.

c. Please briefly explain the specifics of your documented antidepressant
monitoring program(s).

If “No,” please continue.
d. Does your MCO plan on implementing an antidepressant monitoring program
in the future?

 Yes, please specify when you plan on implementing a program to monitor
the appropriate use of antidepressant drugs in children.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

 No, please explain why you will not be implementing a program to
monitor the appropriate use of antidepressant drugs in children.

MOOD STABILIZERS
6. Does your MCO have a documented program in place to either manage or monitor the
appropriate use of mood stabilizing drugs in children?




Yes
No

If “Yes,” please continue.
a. Does your MCO either manage or monitor:


Only children in foster care



All children



Other, please explain.

b. Does your MCO have edits in place to monitor (check all that apply):




Child’s age, please specify age limit: _______years
Dosage

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY





Indication
Polypharmacy
Other, please explain.

c. Please briefly explain the specifics of your documented mood stabilizer
monitoring program(s).

If “No,” please continue.
d. Does your MCO plan on implementing a mood stabilizer monitoring program
in the future?



Yes, please specify when you plan on implementing a program to
monitor the appropriate use of mood stabilizing drugs in children.



No, please explain why you will not be implementing a program to
monitor the appropriate use of a mood stabilizing drugs in children.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
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ANTIANXIETY/SEDATIVES
7. Does your MCO have a documented program in place to either manage or monitor the
appropriate use of antianxiety/sedative drugs in children?




Yes
No
If “Yes,” please continue.
a. Does your MCO either manage or monitor:


Only children in foster care



All children



Other, please explain.

b. Does your MCO have edits in place to monitor (check all that apply):







Child’s age, please specify age limit: _______years
Dosage
Indication
Polypharmacy
Other, please explain.

c. Please briefly explain the specifics of your documented antianxiety/sedative
monitoring program(s).

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

If “No,” please continue.
d. Does your MCO plan on implementing an antianxiety/sedative monitorin g
program in the future?





Yes, please specify when you plan on implementing a program to monitor the
appropriate use of antianxiety/sedative drugs in children.

No, please explain why you will not be implementing a program to monitor
the appropriate use of antianxiety/sedative drugs in children.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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
Innovative Practices Summary 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 PA, continuing education programs).

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

IX. EXECUTIVE SUMMARY
Summary 5: Executive Summary
Please include a general overview and summary of program highlights from FFY 2021 as well
as objectives, tools and outcomes of initiatives accomplished, and goals for FFY 2022. Include
a summary of program oversight and initiatives.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

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
MCO

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.
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 long- term 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.

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.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

Managed Care
Program Type

Definition

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 organization service 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-toface 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.

Non-Emergency
Medical
Transportation
(NEMT)

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.

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

MANAGED CARE PLAN CROSSWALK
The table below provides a crosswalk for plan types to program types.
Managed Care Plan Type

Managed Care Program Type
•
•

Comprehensive MCO
Comprehensive MCO
+MLTSS (if benefits include
LTSS)

Traditional PCCM Provider

•

PCCM

Enhanced PCCM Provider

•

PCCM

HIO

•

Comprehensive MCO

Medical-only PIHP (risk or non-risk/noncomprehensive/with inpatient hospital or
institutional
services)

•

Other PHP

Medical-only PAHP (risk or non-risk/noncomprehensive/no inpatient hospital or
institutional
services)

•

Other PHP

Long Term Care (LTC) PIHP

•

MLTSS Only

Mental Health (MH) PIHP

•

BHO (PIHP and/or PAHP)

Mental Health (MH) PAHP

•

BHO (PIHP and/or PAHP)

Substance Use Disorders (SUD) PIHP

•

BHO (PIHP and/or PAHP)

Substance Use Disorders (SUD) PAHP

•

BHO (PIHP and/or PAHP)

Mental Health (MH) and Substance Use
Disorders (SUD) PIHP

•

BHO (PIHP and/or PAHP)

Mental Health (MH) and Substance Use
Disorders (SUD) PAHP

•

BHO (PIHP and/or PAHP)

Dental PAHP

•

Dental

Transportation PAHP

•

NEMT

Disease Management PAHP

•

Other PHP

PACE

•

PACE

Pharmacy PAHP

•

Other PHP

Accountable Care Organization

•
•
•

Comprehensive MCO
Other PHP
PCCM

Comprehensive MCO

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY

Managed Care Plan Type

Managed Care Program Type

Health/Medical Home

•

PCCM

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