CMS-R-153 Abbreviated MCO Report

FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED 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 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. 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. This abbreviated version of the MCO survey is for MCOs
that have pharmacy benefits covered through the FFS program, but the 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).
Individual managed care plan’s survey results will be published online and will be publicly 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:
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 C4-26-05, Baltimore, Maryland 21244- 1850.

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

I.

DEMOGRAPHIC INFORMATION

State Abbreviation:

Select

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 Section 1927(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(g) covered outpatient drugs.
---------------------If yes, completion of the remaining survey is voluntary--------------------------

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

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 (ER)
OTPs
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 (PA), pharmacist or
technician reviews, etc.) 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 PA process?

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

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

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
RetroDUR Educational Outreach Summary is a report on retrospective profile screening and
educational opportunities during the fiscal year reported. This report 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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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

III. PHYSICIAN ADMINISTERED DRUGS (PAD)
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”, does your MCO have a plan to include this information in your DUR criteria in the
future?
Yes
No

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

IV. FRAUD, WASTE, AND ABUSE (FWA) DETECTION
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
Refer to Office of Inspector General (OIG)
Other, please explain.

2. Does your MCO have a coordinated process in place, 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.
Number of controlled substances
Different prescribers of controlled
substances
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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

Multiple pharmacies

Days’ supply
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.

Does your MCO have the capability to restrict the beneficiary to a prescriber

only?
Yes
No
N/A

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

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

Refer to the appropriate Medical Board
Other, please explain.

4. Does your MCO have a documented process in place that identifies potential FWA of
controlled drugs by pharmacy providers?
Yes
No
If “No”, please explain.

If “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.

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

No, please explain.

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

6. 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.

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED 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 to be in compliance with provisions outlined in
Section 5042 and CMS reporting, beginning in FFY 2023.

1. Does your MCO require prescribers (in your provider agreement) 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
Yes, we have access to the database (check all that apply)
Can query by client
Can query by prescriber
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Can query by dispensing entity
No, please explain

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

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

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

C. OPIOIDS
1. Does your MCO 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. Does your MCO have comprehensive automated retrospective claims review
process tomonitor opioid prescriptions exceeding state defined limitations?
Yes, please explain in detail the scope and nature of these retrospective reviews.

No, please explain.

3. Does your MCO 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

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

Please explain above response and detail the scope and nature of these reviews and
edits. Additionally, please explain any potential titration processes utilized for those
patients chronically on benzodiazepines and how the state justifies pain medications,
i.e. Oxycodone/APAP, for breakthrough pain without jeopardizing patient care (i.e.
quantity limits/practitioner education titration programs).

No, please explain.

4. Does your MCO coordinate with the entity that provides the drug benefits to monitor
opioids and sedatives being used concurrently?
Yes, automated retrospective claim 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.

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

No, please explain.

5. Does your MCO coordinate with the entity that provides the drug benefits to monitor
opioids and antipsychotics being used concurrently?
Yes, automated retrospective claim 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.

No, please explain.

6. Does your MCO 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, automated retrospective claim reviews and/or provider education
Yes, both POS edits and automated retrospective claim
reviews and/or provider education
No
If the answer to question 6 is “Yes, automated retrospective reviews and/or provider
education,” please continue.
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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

a. Please indicate how often:
Monthly
Quarterly
Semi-Annually
Annually
Ad hoc
Other, please specify.

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

If the answer to question 6 is “No”, does your MCO plan on implementing an
automated retrospective claims review 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.

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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.

If “No," please explain why no guidelines are offered.

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D. MORPHINE MILLIGRAM EQUIVALENT (MME) DAILY DOSE
1. Does your MCO coordinate with the entity that provides the drug benefit to monitor MME
total daily dose of opioid prescriptions dispensed?
Yes
No
Please explain above response.

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E. OPIOID USE DISORDER (OUD) TREATMENT
1. Does your MCO coordinate with the entity that provides the drug benefit to monitor and
manage appropriate use of naloxone to persons at risk of overdose?
Yes
No
Please explain above response.

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F. OPIOID TREATMENT 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.

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G. PSYCHOTROPHIC MEDICATION
ANTIPSYCHOTICS
1. Does your MCO coordinate with the entity that provides the drug benefit 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, does
your MCO plan on implementing a program in the future?
Yes, please specify when.

No, please explain why your MCO will not be implementing a program to

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

monitor the appropriate use of antipsychotic drugs in children.
STIMULANTS
2. Does your MCO coordinate with the entity that provides the drug benefit 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 monitorin g
program(s).

If you do not have a documented stimulant monitoring program in place, does your
MCO plan on implementing a program in the future?
Yes, please specify when.

No, please explain why your MCO will not be implementing a program to
monitor the appropriate use of stimulant drugs in children.
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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

ANTIDEPRESSANTS/MOOD STABILIZERS/ANTIAXIETY/SEDATIVES
3. Does your MCO coordinate with the entity that provides the drug benefit to either manage
or monitor the appropriate use of other psychotropic medication (antidepressants, mood
stabilizers, antianxiety/sedative) drugs in children?
Yes (check all that apply)
Antidepressants
Mood stabilizers
Antianxiety/sedative drugs
Other, please explain.

No

If “Yes”, please continue.
a. Do you either manage or monitor
Only children in foster care
All children

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Other, please explain.

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

If you do not have a documented monitoring program in place, does your MCO plan
on implementing a program in the future?
Yes, please specify when.

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

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DRUG UTILIZATION REVIEW (DUR) ANNUALABBREVIATED SURVEY

V. 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 2 – Innovative Practices
Has your MCO developed any innovative practices during the past year (i.e. Substance Use
Disorder, Hepatitis C, Cystic Fibrosis, MMEs, Value Based Purchasing)? Please describe in
a 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 PA, continuing
education programs).

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