Download:
pdf |
pdfFFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
ABOUT THE SURVEY
Section 1927(g)(3)(D) of the Social Security Act (the Act) requires each state to submit an annual
report on the operation of its Medicaid Drug Utilization Review (DUR) program. Such reports are
to include: descriptions of the nature and scope of the prospective and retrospective DUR programs;
a summary of the interventions used in retrospective DUR and an assessment of the education
program; a description of DUR Board activities; and an assessment of the DUR program’s impact
on quality of care as well as any cost savings generated by the program.
Note: Covered Outpatient Drugs (COD) are referenced throughout this survey and refers to
participating labelers in the Medicaid Drug Rebate Program (MDRP).
This report covers the period October 1, 2023 to September 30, 2024 and is due for submission to
Centers for Medicare & Medicaid Services (CMS) Central Office by no later than June 30, 2025.
Answering the attached que stions and returning the re quested materials as attachments to the
report will constitute compliance with the above -mentioned statutory requirement.
CMS does not edit state responses; therefore, what is submitted by the state will be what is posted
on Medicaid.gov. This material is also utilized for composing the annual report to Congress.
If you have any questions regarding the DUR Annual Report, please contact CMS via email at:
[email protected].
PRA DISCLOSURE STATEMENT (CMS-R-153)
This mandatory information collection (section 4401 of the Omnibus Budget Reconciliation Act of 1990 and section
1927(g) of the Social Security Act) is necessary to establish patient profiles in pharmacies, identify problems in
prescribing and/or dispensing, determine each program’s ability to meet minimum standards required for federal
financial participation, and ensure quality pharmaceutical care for Medicaid patients. State Medicaid agencies that have
prescription drug programs are required to perform prospective and retrospective DUR in order to identify aberrations
in prescribing, dispensing and/or patient behavior. Under the Privacy Act of 1974 any personally identifying
information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid Office of Management and
Budget (OMB) control number. The control number for this information collection request is 0938-0659 (Expires:
XX/XX/XXXX). Public burden for all of the collection of information requirements under this control number is
estimated at 65 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.
I have read the information about this survey.
1|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
I. DEMOGRAPHIC INFORMATION
State Abbreviation:
Medicaid Program Information
Identify sstate person responsible for DUR Annual Report Preparation.
First Name:
Last Name:
Email Address:
Position Title:
1. On a monthly average, how many of your sstate’s Medicaid beneficiaries are
enrolled in your sstate's Medicaid Fee-For-Service (FFS) program that have a
pharmacy benefit?
Beneficiaries
2. On a monthly average, how many of your sstate's Medicaid beneficiaries are
enrolled in managed care plan(s) that provide drug benefit(s)?
Beneficiaries
2|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
II. PROSPECTIVE DUR (ProDUR)
1. Indicate the type of your pharmacy point of service (POS) vendor.
State-Operated
Contractor
Other
a. Vendor Name
b. Who processes the sstate’s National Council for Prescription Drug Programs
(NCPDP) transactions?
POS vendor is the fiscal agent (FA)
POS vendor is a separate Pharmacy Benefits Manager (PBM)
Other, please explain.
____________________________________________________________
____________________________________
____________________________________
2. Identify your ProDUR table driven criteria source. This would be initial ratings such
as drug to drug interactions, dose limits based on age, etc… . Check all that apply.
First Databank
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 “NCPDP
drug use evaluation codes” (reason for service, professional service and resolution)?
Yes
Varies by alert type
No
If “Yes” or “Varies by Alert Type,” check all that apply.
Alerts can be overridden ahead of time
Alerts can be overridden with standard professional codes
3|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Alerts need prior authorization (PA) to be overridden
Other, please explain.
4. Does your sstate receive periodic reports providing individua l pharmacy providers
DUR alert override activity in summary and/or in detail?
Yes
No, please explain.
a. If “Yes,” how often does your sstate receive reports?
Monthly
Quarterly
Annually
Ad hoc (on request)
Other, please explain.
b. If ”Yes,”, does your sstate follow up with those providers who routinely
override with interventions?
Yes
If “Yes,” by what method does your sstate follow up? Check all that apply:
Contact Pharmacy
Refer to Program Integrity for Review
Other, please explain.
4|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
No, please explain.
5. Early Refill
a. At what percent threshold does your sstate 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 sstate require a PA?
Yes
No
Dependent on medication or situation
If “Yes” or “Dependent on medication or situation,” who obtains
authorization?
Pharmacist
Prescriber
Pharmacist or Prescriber
If “No,” can the pharmacist override at the POS?
Yes
No
5|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
c. For controlled drugs:
When an early refill message occurs, does your sstate require a PA?
Yes
No
If “Yes,” who obtains authorization?
Pharmacist
Prescriber
Pharmacist or Prescriber
If “No,” can the pharmacist override at the POS?
Yes
No
6. When the pharmacist receives an early refill DUR alert message that requires the
pharmacist’s review, does your sstate’s policy allow the pharmacist to override for
situations such as (check all that apply):
Lost/stolen RX
Vacation
Overrides are only allowed by a pharmacist through a PA
Other, please explain.
7. Does your system have an accumulation edit to prevent patients from continuously
filling prescriptions early?
Yes
No
If “Yes,” please explain your edit.
6|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
If “No,” does your sstate plan to implement this edit?
Yes
No
8. Does the sstate Medicaid program have any policy prohibiting the auto-refill process
that occurs at the POS (i.e. must obtain beneficiary's consent prior to enrolling in the
auto-refill program)?
Yes
No
9. Does your system have a diagnosis edit that can be utilized when processing a prescription?
Yes, please explain.
No
10. Does your Medicaid program have a documented process (i.e. PA) in place, so that the
Medicaid beneficiary or the Medicaid beneficiary’s prescriber may access any rebate
participating manufacturer covered outpatient drug when medically necessary?
Yes
Please check all that apply.
Automatic PA based on diagnosis codes or systematic review
Trial and failure of first or second-line therapies to support Preferred Drug List
Pharmacist or technician reviews
Direct involvement with Pharmacy and/or Medical Director
7|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Other, please explain.
No, please explain why not.
__________________________________________________________________________________________________
___________________________________________________________________________________________________
a. Does your program provide for the dispensing of at least a 72-hour supply of a
covered outpatient drug (COD) in an emergency situation? Please check all that
apply.
Real-time automated process
Retrospective PA
Other process, please explain.
11. 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
8|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Column 7 – From Data in Column 6, determine the Percentage of Total Claims
9|Page
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
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
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
Top 10 Prior Authorization (PA)
Requests by Drug Name, report at
generic ingredient level
Top 10 Prior Authorization
(PA) Requests by Drug Class
Top 5 Claim Denial Reasons (i.e.
Quantity Limits (QL), Early Refill (ER),
PA, Therapeutic Duplications (TD) and
Age Edits (AE))
Top 10 Drug Names by Amount Paid,
report at generic ingredient level
% of Total
Spent for
Drugs by
Amount Paid
(From data in
Column 4,
Determine the
% of total
drug spend)
Top 10 Drug Names by Claim Count,
report at generic ingredient level
Drugs by
Claim Count
% of Total
Claims
(From data in
Column 6,
Determine the
% of total
claims)
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
10 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
12. Section 1927(g)(A) of the Act requires that the pharmacist offer patient counseling
at the time of dispensing. Who in your sstate has responsibility for monitoring
compliance with the oral counseling requirement? Check all that apply.
Medicaid Program
State Board of Pharmacy
Other, please explain.
a. Please explain the steps taken by the state agency to monitor compliance by
pharmacies with the prospective DUR counseling requirements contained in
federal and state laws and regulations.
11 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
III. RETROSPECTIVE DUR (RetroDUR)
1. Indicate the type of vendor that performed your RetroDUR activities during the time
period covered by this report.
Vendor
Academic Institution
Other Institution
a. Identify, by name, your RetroDUR vendor.
b. Is the RetroDUR vendor the Medicaid Management Information System (MMIS)
fiscal agent?
Yes
No
c. Is the RetroDUR vendor the developer/supplier of your retrospective DUR criteria?
Yes
No
Please explain “Yes” or “No” response.
d. Does your sstate customize your RetroDUR vendor criteria?
Yes
No
Ad hoc based on sstate-specific needs
2. How often does your sstate perform retrospective practitioner-based education?
Monthly
Bi-monthly
Quarterly
Other, please specify.
12 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
a. How often does your sstate perform retrospective reviews that involve
communication of client specific information to healthcare practitioners
(through messaging, fax, or mail)? Check all that apply.
Monthly
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
3. Summary 1 – RetroDUR Educational Outreach
RetroDUR Educational Outreach Summary should be a year-end 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.
13 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
14 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
IV. DUR BOARD ACTIVITY
1. Does your sstate have an approved Medication Therapy Management
(MTM) Program?
Yes
No
2. Does your state have a separate advisory board for your PDL?
Yes
No
3. Summary 2 – DUR Board Activities
DUR Board Activities Summary should include a brief descriptive 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:
o For ProDUR, list problem type/drug combinations added or deleted.
o For RetroDUR, list therapeutic categories added or deleted.
•
Describe Board policies that establish whether and how results of
ProDUR screening are used to adjust RetroDUR screens.
•
Describe policies that establish whether and how results of RetroDUR
screening are used to adjust ProDUR screens.
•
Describe DUR Board involvement in the DUR education program (i.e.
newsletters, continuing education, etc.).
•
Describe policies adopted to determine the mix of patient or provider
specific intervention types (i.e. letters, face-to-face visits, increased
monitoring).
15 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
V. PHYSICIAN ADMINISTERED DRUGS (PAD)
The Deficit Reduction Act required collection of national drug code (NDC) numbers for
covered outpatient physician administered drugs. These drugs are paid through the
medical benefit. Has your MMIS been designed to incorporate this data into your DUR
criteria for:
1. ProDUR?
Yes
No
If “No,” does your state have a plan to include this information in your DUR
criteria in the future?
Yes
No
2. RetroDUR?
Yes
No
If “No,” does your state have a plan to include this information in your DUR
criteria in the future?
Yes
No
16 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
VI. GENERIC POLICY AND UTILIZATION DATA
1. 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.
2. In addition to the requirement that the prescriber write in his own handwriting “Brand
Medically Necessary” for a brand name drug to be dispensed in lieu of the generic
equivalent, does your state have a more restrictive requirement?
Yes
No
If “Yes,” check all that apply.
Require that a MedWatch Form be submitted
Require the medical reason(s) for override accompany the prescription(s)
Prior authorization (PA) is required
Other, please explain.
17 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Table 2: Generic Drug Utilization Data
Computation Instructions
KEY
Single Source (S) – Drugs having an FDA New Drug Application (NDA), and
there are no generic alternatives available on the market.
Non-Innovator Multiple-Source (N) – Drugs that have an FDA Abbreviated New
Drug Application (ANDA), and generic alternatives exist on the market.
Innovator Multiple-Source (I) – Drugs which have an NDA and no longer have
patent exclusivity.
1. Generic Utilization Percentage: To determine the generic utilization percentage
of all covered outpatient drugs paid during this reporting period, use the following
formula:
N ÷ (S + N + I) × 100 = Generic Utilization Percentage
2. Generic Expenditures Percentage of Total Drug Expenditures: To determine
the generic expenditure percentage (rounded to the nearest $1000) for all covered
outpatient drugs for this reporting period use the following formula:
$N ÷ ($S + $N + $I) × 100 = Generic Expenditure Percentage
CMS has developed an extract file from the Medicaid Drug Rebate Program Drug Product Data File
identifying each NDC along with sourcing status of each drug: S, N, or I, which can be found at
Medicaid.gov (Click on the link “National Drug Code and Drug Category file [ZIP],” then open the
Medicaid Drug Product File 4th Qtr. Excel file).
Please provide the following utilization data for this DUR reporting period for all covered
outpatient drugs paid. Exclude Third Party Liability (TPL).
Single Source (S)
Drugs
Non-Innovator (N)
Drugs
Innovator Multi-Source (I)
Drugs
Total Number of Claims
Total Reimbursement
Amount Less Co-Pay
18 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
3. Indicate the generic utilization percentage for all covered outpatient drugs (COD) paid
during this reporting period, using the computation instructions in Table 2 – Generic
Drug Utilization Data.
Number of Generic Claims:
Total Number of Claims:
Generic Utilization Percentage:
4.
%
Does your Medicaid program have a brand over generic program when the brand
product nets a lower cost.
Yes
No
5. 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 Data.
Generic Dollars:
$
Total Dollars:
$
Generic Expenditure Percentage:
6. Does your state have any policies related to biosimilars?
%
Please explain.
19 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
VII.
PROGRAM EVALUATION/COST SAVINGS/COST AVOIDANCE
1. Did your state conduct a DUR program evaluation of the estimated cost savings/cost
avoidance?
Yes
No
If “Yes,” identify, by name and type, the institution that conducted the program
evaluation.
Institution Type
Vendor
Academic Institution
Other Institution
Institution Name
2. Please provide your ProDUR and RetroDUR program cost savings/cost avoidance in
the chart below.
Cost in Dollars
ProDUR Total Estimated Avoided Costs
RetroDUR Total Estimated Avoided Costs
Other Cost Avoidance
Grand Total Estimate d Avoided Costs
3. The Estimated Percent Impact was generated by dividing the Grand Total Estimated
Avoided Costs from Question 2 above by the Total Dollar Amount provided in Section
VI, Question 5, then multiplying this value by 100.
Estimated Percent Impact:
%
4. Does your program allow pharmacists to order either prescription or OTCs medications
through:
20 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
State Board of Professional Regulations/Board of Pharmacy/Board of Medicine
and/or State Medicaid program under protocol
Collaborative practice agreements
Standing orders
Other predetermined protocols
___________________________________
What categories of drugs are dispensed through these types of agreements?
_____________________________
______________________________
5. Summary 4 – Cost Savings/Cost Avoidance Methodology
Cost Savings/Cost Avoidance Methodology Summary should include program
evaluations/cost savings estimates prepared by the state or contractor. Please
provide detailed summary below.
21 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
VIII. FRAUD WASTE, AND ABUSE DETECTION
B.
LOCK-IN or PATIENT REVIEW AND RESTRICTION PROGRAMS
1. Does your state have a documented process in place that identifies potential fraud or
abuse of controlled drugs by beneficiaries?
Yes
No, please explain why not.
If “Yes,” what actions does this process initiate?
Check all that apply:
Deny claims
Refer to Office of Inspector General (OIG)
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
Other, please explain.
2. Does your state have a Lock-In program for beneficiaries with potential misuse or
abuse of controlled substances?
Yes
No
If “No”, skip to question 3.
22 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
If “Yes,” please continue.
a. What criteria does your state use to identify candidates for Lock-In? Check all
that apply:
Number of controlled substances (CS)
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
Other, please explain.
b. Does your state 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
As determined by the state on a case-by-case basis
24 months
23 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Lock-in time period is based on number of incidences/occurrences
Other, please explain.
d. On average, what percentage of the FFS 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 or N/A if your state does not estimate savings.
$
N/A
3. Does your state have a documented process in place that identifies possible FWA of
controlled drugs by pre scribers?
Yes
What actions does this process initiate?
Check all that apply:
Deny claims written by this prescriber
Refer to the appropriate Medical Board
Refer to Program Integrity Unit (PIU) and/or Surveillance Utilization
Review (SUR) Unit for audit/investigation
Other, please explain.
No, please explain why not.
24 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
4. Does your state have a documented process in place that identifies potential FWA of
controlled drugs by pharmacy providers?
Yes
What actions does this process initiate?
Check all that apply:
Deny claim
Refer to Program Integrity Unit (PIU) and/or Surveillance Utilization Review
(SUR) Unit for audit/investigation
Refer to Board of Pharmacy
Other, please explain.
No, please explain why not.
5. Does your state have a documented process in place that identifies and/or prevents
potential FWA of non-controlled drugs by beneficiaries, prescribers, and pharmacy
providers?
Yes, please explain your program for FWA of non-controlled substances.
No, please explain why not.
6. Briefly explain the states’ objectives and scope of responsibility between DUR and SUR
25 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
functions as they relate to FWA. Additionally, explain how the state maintains separation
between fraud and abuse and educational activities. (Character limit 1000)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
26 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
C.
PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
1. Does your Medicaid program have the ability to query the state’s PDMP database?
Yes, for all data files
Yes, for selective beneficiary and provider searches
No, please explain.
If “Yes,” please continue.
Please check all applicable ways the state accesses the PDMP database.
i.
Receive PDMP data
Direct access to the database
ii.
If “Receive PDMP data,” please indicate how often. Check all that apply.
Daily
Weekly
Monthly
Other
If “Direct access to the database,” please specify. Check all that apply.
Can query by client
Can query by prescriber
Can query by dispensing entity
Please explain how the state applies this information to control FWA of controlled
substances.
27 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Does your state also have access to contiguous states’ PDMP information?
Yes
No
In the state’s PDMP system, which of the following beneficiary information 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.
Are there barriers that hinder the Medicaid agency 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
How have you communicated to prescribers who are covered providers that they are
required to check the PDMP before prescribing controlled substances to beneficiaries
who are covered individuals? Check all that apply.
Provider bulletin
Program website
Provider blast fax
DUR letter
28 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Public notice
Provider manual
RetroDUR communication
Other, please explain.
No, please explain.
Has the state specified protocols for prescribers checking the PDMP?
Yes, please explain.
No
Do providers receive protocols for responses to information from the PDMP that is
contradictory to information that the practitioner expects to receive (example:
when a provider prescribing pain management medication finds medications for
opioid use disorder (OUD) during a PDMP check, when client denies opioid use
disorder)?
Yes
No
If a provider is not able to conduct PDMP check, does your state require the
prescriber to document a good faith effort, including the reasons why the provider
was not able to conduct the check?
Yes
No, please explain why not.
29 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
If “Yes,” does your state require the provider to submit, upon request,
documentation to the state?
Yes
No, please explain.
Please specify below the following information for the 12-month reporting period for
this survey.
Does your state or professional board require pharmacists to check the PDMP prior
to dispensing a controlled substance to a covered individual?
Yes
No, please explain.
If “Yes,” are there protocols involved for pharmacists in checking the PDMP?
Yes, please explain.
No
30 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
The percentage of covered providers (as determined pursuant to a process
established by the state) who checked the prescription drug history of a beneficiary
through a PDMP before prescribing a controlled substance to such an individual:
%
i. How was the above calculation obtained?
A provider survey
A provider attestation
A PDMP vendor report
Raw PDMP data using the median
Other, please explain.
For sub questions d., e., f., g and the Tables 3, 4, 5 and 6 below, please
specify the type of data utilized in determining the calculations.
Raw PDMP data
MMIS claims
A PDMP vendor report
Multiple data sources, please explain which source is used for each question
below.
Other, please explain.
i. Do these calculations include cash payments?
Yes
No
d. Total morphine milligram equivalents (MME) dispensed in 12 month reporting period:
_________ MME
e. Total MME dispensed per covered individual:
_________ MME
f. Total MME dispensed per covered individual who received an opioid prescription:
31 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
_________ MME
g. Average daily MME dispensed per opioid prescription:
MME
h. 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 12-month FFY reporting period.
a. statestatestate
32 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Table 3: Opioid Controlled Substance s by Population
Population
Column 1
Total Number
of Beneficiaries
Within Each
Age Group
Column 2
Total Number of Unique
Beneficiaries Within Each Age
Group Receiving an Opioid
Controlled Substance in the 12
Month Reporting Period
Column 3Percentage of
Unique Beneficiaries
Within Each Age Group Receiving
an Opioid Controlled Substance in
the 12 Month Reporting Period
Column 4
Top 3 Opioid Controlled
Substances Received Within Each
Age Group (Generic Ingredient) in
the 12 Month Reporting Period
Column 5
Number of Unique Beneficiaries
Within Each Age Group Receiving
the Opioid Controlled Substance
(Specified in Column 4) in the 12
Month Reporting Period
Column 6
Percentage of Unique Beneficiaries
Within Each Age Group Receiving
the Top 3 Opioid Controlled
Substances (Specified in Column 4)
in the 12 Month Reporting 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
Categories
33 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Table 4: Top Se dative /Benzodiazepine s Controlled Substance s 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
Column 1
Total Number
of Beneficiaries
Within Each
Age Group
Column 2
Total Number of Unique
Beneficiaries Within Each Age
Group Receiving a
Sedative/Benzodiazepine in the 12
Month Reporting Period
Column 3
Percentage of Unique Beneficiaries
Within Each Age Group Receiving
a Sedative/Benzodiazepine in the 12
Month Reporting Period
Column 4
Top 3 Sedative/Benzodiazepine
Received Within Each Age Group
(Generic Ingredient) in the 12
Month Reporting Period
Column 5
Number of Unique Beneficiaries
Within Each Age Group Receiving
the Sedative/Benzodiazepine
(Specified in Column 4) in the 12
Month Reporting Period
Column 6
Percentage of Unique Beneficiaries
Within Each Age Group Receiving
the Top 3 Sedative/Benzodiazepine
(Specified in Column 4) in the 12
Month Reporting 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
Categories
34 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Table 5: Top Stimulant/ADHD Controlled Substance s 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
Column 1
Total Number
of Beneficiaries
Within Each
Age Group
Column 2
Total Number of Unique
Beneficiaries Within Each Age
Group Receiving a
Stimulant/ADHD Controlled
Substance in the 12 Month
Reporting Period
Column 3
Percentage of Unique Beneficiaries
Within Each Age Group Receiving
a Stimulant/ADHD Controlled
Substance in the 12 Month
Reporting Period
Column 4
Top 3 Stimulant/ADHD Controlled
Substances Received Within Each
Age Group (Generic Ingredient) in
the 12 Month Reporting Period
Column 5
Number of Unique Beneficiaries
Within Each Age Group Receiving
the Stimulant/ADHD Controlled
Substance (Specified in Column
4) in the 12 Month Reporting
Period
Column 6
Percentage of Unique Beneficiaries
Within Each Age Group Receiving
the Top 3 Stimulant/ADHD
Controlled Substance (Specified
in Column 4) in the 12 Month
Reporting 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
Categories
35 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Table 6: Populations on 2 or more Controlled Substance s 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
Total Number of
Beneficiaries within Each
Age Group
Column 2
Number of Unique Beneficiaries in Each
Age Group/Month Receiving 2 or more
Controlled Substances in Different Drug
Categories per Month Averaged for the
12 Month Reporting Period
Column 3
Percentage of Age Group Receiving 2 or
More Controlled Substances per Month
Averaged for the 12 Month Reporting
Period
Column 4
Number of Unique Beneficiaries in Each
Age Group Receiving 3 or more
Controlled Substances in Different Drug
Categories per Month Averaged for the
12 Month Reporting Period
Column 5
Percentage of Age Group Receiving 3 or
more Controlled Substances per Month
Averaged for the 12 Month Reporting
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
Categories
36 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
i. If there is additional information you want to provide about the calculations
and/or the Tables above for the 12- month reporting period, please explain
below or specify N/A if not applicable .
j. Has your state exempted certain individuals, (see the definition of Covered
Individuals under section 1944(h)(2) of the Act, as added by Section 5042 of
the SUPPORT Act), from the associated reporting requirements? Check all
that apply.
Individuals receiving hospice
Individuals receiving palliative care
Individuals receiving cancer treatments
Residents of long-term care facilities or other facility specified in
section 1944(g)(2)(B)
Babies with neonatal abstinence syndrome (also called NAS)
Other population 1, please explain
Other population 2, please explain
Other population 3, please explain
i. If any of the information requested is not being reported above,
please explain below or specify N/A if not applicable .
5. Have you had any changes to your state’s PDMP during this reporting period
that have improved the Medicaid program’s ability to access PDMP data?
Yes, please explain.
No
37 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
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
No
If “Yes,” please summarize the breach, the number of individua ls impacted, a
description of the steps the state has taken to address each such breach, and if law
enforcement or the affected individua ls were notified of the breach.
38 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
D.
OPIOIDS
1. Does your state 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 why not.
If the answer to question 1 is “Yes, for all opioids” or “Yes, for some opioids,” please
continue. If the answer to question 1 is “No,” please skip to 1b.
a. What is the maximum number of days allowed for an initial opioid prescription
for an opioid naïve patient?
# of days
b. Does your state 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, please explain.
90-day supply
2. Does your state have POS edits in place to limit the quantity dispensed of opioids?
39 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Yes
No, please explain why not.
If “Yes,” please continue.
a. Does your state have POS edits in place to limit the quantity dispensed of
short- acting (SA) opioids?
Yes
Other, please explain.
No, please explain.
b. Does your state currently have POS edits in place to limit the quantity dispensed
of long-acting (LA) opioids?
Yes
Other, please explain.
No, please explain.
40 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
3. Does your state have measures other than restricted quantities and days’ supply in
place to either monitor or manage the prescribing of opioids?
Yes
No
If “Yes,” check all that apply.
Pharmacist override
Deny claim and require PA
Intervention letters
MME daily dose program
Step therapy or clinical criteria
Requirement that patient has a pain management contract or PatientProvider agreement
Requirement that prescriber has an opioid treatment plan for patients
Require documentation of urine drug screening results
Require diagnosis
Require PDMP checks
Workgroups to address opioids
Other, please specify.
Please provide details on these opioid prescribing controls in place.
If “No,” please explain what you do in lieu of the above or why you do not have
measures in place to either manage or monitor the prescribing of opioids.
41 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
4. Does your state 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 why not.
5.Does your state have POS edits to monitor early refills of opioid prescriptions
dispensed?
Yes, POS edits
Yes, both POS edits and automated retrospective claims review process
No, please explain why not.
6. Does your state have comprehensive automated retrospective claim reviews to
monitor opioid prescriptions exceeding these state limitations (early refills,
duplicate fills, quantity limits and days’ supply)?
Yes, please explain in detail scope, nature, and frequency of these retrospective
reviews.
No, please explain why not.
42 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
7. Does your state currently have automated retrospective claim reviews to monitor
opioids and benzodiazepines being used concurrently?
Yes, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
Please explain above response and detail the scope and nature of 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 why not.
8. Does your state currently have automated retrospective claim reviews to monitor
opioids and sedatives being used concurrently?
Yes, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
No, please explain why not.
9. Does your state currently have automated retrospective claim reviews to monitor
opioids and antipsychotics being used concurrently?
43 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Yes, automated retrospective claim reviews
Yes, both POS edits and automated retrospective claim reviews
No, please explain why not.
10. Does your state have POS safety edits or perform automated retrospective claim
reviews and/or provider education in regard to beneficiaries with a diagnosis history
of opioid use disorder (OUD) or opioid poisoning diagnosis?
Yes
No, please explain why not.
If “Yes,” please check all that apply.
POS edits
Automated retrospective claim reviews
Provider education
If Automated retrospective claim reviews and/or “Provider education,”
please indicate how often.
Monthly
Quarterly
Annually
Ad hoc
Semi-Annually
Other, please specify.
44 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
If “No,” does your state plan on implementing POS edits, automated
retrospective claim reviews and/or provider education in regard to beneficiaries
with a diagnosis history of OUD or opioid poisoning in the future?
Yes, when does your state plan on implementing?
No, please explain why not.
11. Does your state Medicaid program develop and provide prescribers with pain
management or opioid prescribing guidelines?
Yes
No
If “Yes,” please check all that apply.
Your state Medicaid program refers prescribers to the Center for Disease
Control (CDC) 2022 Clinical Practice Guideline for Prescribing Opioids
for Pain.
Other guidelines, please identify.
If “No,” please explain why no guidelines are offered.
45 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
12. Does your state 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, please explain
13. Have there been state specific events (unplanned outages, natural
disasters, public health emergencies, etc…) that have had
ramifications on edits, reviews or prescribing for this reporting period?
Yes, please explain.
No
46 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
E.
MORPHINE MILLIGRAM EQUIVALENT (MME) DAILY DOSE
1. Have you set recommended maximum MME daily dose measures?
Yes
No
If “Yes,” please continue.
a. What is your maximum morphine equivalent daily dose limit in milligrams?
Less than 50 MME, please specify:
50 MME
70 MME
80 MME
90 MME
100 MME
120 MME
200 MME
Greater than 200 MME, please specify.
Other, please specify.
mg per day
mg per day
mg per day
More than 1 MME accessed in state
b. Please explain nature and scope of dose limit (i.e. Who does the edit apply to?,
Does it apply to new users/chronic users?, Does the limit apply to all opioids?,
Are you in the process of tapering patients to achieve this limit?).
If “No,” please explain why not.
2. Does your state have an edit in your POS system that alerts the pharmacy provider that
the MME daily dose prescribed has been exceeded?
Yes
No, please explain why not.
__________________________________________________________________
47 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
__________________________________________________________________
__________________________________________________________________
If “Yes,” does your state require PA if the MME limit is exceeded?
Yes
No
3. Does your state have automated retrospective claim reviews to monitor the MME total
daily dose of opioid prescriptions dispensed?
Yes
No, please explain why not.
4. Do you provide information to your prescribers on how to calculate the MME daily
dosage or do you 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.
b. How is the information disseminated?
Check all that apply.
Website
Provider notice
48 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Educational seminar
Other, please explain.
49 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
F.
OPIOID USE DISORDER (OUD) TREATMENT
1. Does your state have utilization controls (i.e. preferred drug list (PDL), prior
authorization (PA), quantity limit (QL)) to either monitor or manage the prescribing of
Medication Assisted Treatment (MAT) drugs for OUD?
Yes, please explain.
No, please explain.
2. Does your Medicaid program set total mg per day limits on the use of buprenorphine
and buprenorphine/naloxone combination drugs?
Yes
No
If “Yes,” please specify the total mg/day:
12 mg
24 mg
32 mg
16 mg
Other, please explain.
3. What are your limitations on the allowable length of this treatment?
50 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
No limit
3 months or less
6 months
Other, please explain.
12 months
24 months
4. Does your state 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
Other, please explain.
16 mg
b. What are your limitations on the allowable length of the reduced dosage
treatment?
No limit
12 months
Other, please explain.
6 months
51 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
5. Does your state have at least one buprenorphine/naloxone combination product
available without PA?
Yes
No
6. Does your state currently have edits in place to monitor opioids being used concurrently
with any buprenorphine drug or any form of MAT?
Yes
No, please explain why not.
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 state have at least one opioid reversal agent available without PA?
Yes
No
9. Does your state monitor and manage appropriate use of opioid reversal agents to
persons at risk of overdose?
Yes
No, please explain why not.
52 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
10. Does your State Board of Professional Regulations/Board of Pharmacy/Board of
Medicine and/or state Medicaid program allow pharmacists to dispense naloxone
prescribed independently or by collaborative practice agreements, standing orders, or
other predetermined protocols?
Yes, State Board of Professional Regulations/Board of Pharmacy/Board of
Medicine and/or state Medicaid program under protocol
Yes, prescribed independently
No
53 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
G.
OUTPATIENT TREATMENT PROGRAMS (OTP)
1. Does your state cover OTPs that provide Behavioral Health (BH) and MAT services?
Yes
No, please explain why not.
If “Yes”, is a referral needed for OUD treatment through OTPs?
Yes
No
Please explain.
2. Does your state Medicaid program cover buprenorphine or buprenorphine/naloxone
for diagnoses of OUD as part of a comprehensive MAT treatment plan through
OTPs?
Yes
No, please explain.
3. Does your state Medicaid program cover naltrexone for diagnoses of OUD as part of
a comprehensive MAT treatment plan?
Yes
No, please explain.
54 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
55 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
H.
PSYCHOTROPIC MEDICATION ANTIPSYCHOTICS
1. Does your state have a documented program in place to manage and monitor the
appropriate use of antipsychotic drugs in children?
Yes
No
If “Yes,” please continue.
a. Does your state manage and monitor:
Only children in foster care under 18 y.o.
Other, please explain.
All children including foster care under 18 y.o.
b. Does your state have edits in place to monitor(check all that apply):
Child’s age
Dosage
Indication
Polypharmacy
Other, please explain.
c. Please briefly explain the specifics of your documented
monitoring program(s).
antipsychotic
56 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
If “No,” please continue.
Does your state 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.
2. Does your state have a documented program in place to manage and monitor the
appropriate use of antipsychotic drugs in individuals over the age of 18 receiving
home and community-based services (as defined in section 9817(a)(2)(B) of Public
Law 117–2)?
Yes
No
If “Yes,” please continue.
Does your state have edits in place to monitor(check all that apply):
Dosage
Indication
Polypharmacy
Other, please explain.
57 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Please briefly explain the specifics of your documented
monitoring program(s).
antipsychotic
If “No,” please continue.
Does your state plan on implementing an antipsychotic monitoring program in
the future?
Yes, please specify when you plan on implementing a program.
No, please explain why you will not be implementing a program.
3. Does your state have a documented program in place to manage and monitor the
appropriate use of antipsychotic drugs in individuals over the age of 18 residing in
institutional care settings (including nursing facilities, intermediate care facilities for
individuals with intellectual disabilities, institutions for mental diseases, inpatient
psychiatric hospitals, and other such institutional care settings)?
Yes
No
If “Yes,” please continue.
58 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Does your state monitor (check all that apply):
individuals over the age of 18 residing in nursing facilities
individuals over the age of 18 residing in institutions for mental diseases
individuals over the age of 18 residing in intermediate care facilities for
individuals with intellectual disabilities
individuals over the age of 18 residing in patient psychiatric hospitals
individuals over the age of 18 residing in other such institutional care
settings. Please explain.
If your state does not monitor all of the above, please explain why not.
Does your state have edits in place to monitor (check all that apply):
Dosage
Indication
Polypharmacy
Other, please explain.
Please briefly explain the specifics of your documented
monitoring program(s).
antipsychotic
If “No,” please continue.
Does your state plan on implementing an antipsychotic monitoring program in
59 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
the future?
Yes, please specify when you plan on implementing a program.
No, please explain why you will not be implementing a program.
STIMULANTS
4. Does your state have a documented program in place to manage and monitor the
appropriate use of stimulant drugs in children?
Yes
No
If “Yes,” please continue.
a. Does your state manage and monitor:
Only children in foster care under 18 y.o.
All children including foster care under 18 y.o.
Other, please explain.
b. Does your state have edits in place to monitor(check all that apply):
Child’s age
Dosage
Indication
60 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
Polypharmacy
Other, please explain.
c. Please briefly explain the specifics of your documented stimulant monitoring
program(s).
______________________________________________________________________________________________
____________________________________________________________________________
If “No,” please continue.
d. Does your state 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 state have a documented program in place to manage and monitor the
appropriate use of antidepressant drugs in children?
Yes
No
61 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
If “Yes,” please continue.
a. Does your state manage and monitor:
Only children in foster care under 18 y.o.
All children including foster care under 18 y.o.
Other, please explain.
b. Does your state have edits in place to monitor (check all that apply):
Child’s age
Dosage
Indication
Polypharmacy
Other, please explain.
c. Please briefly explain the specifics of your documented antidepressant
monitoring program(s).
If “No,” please continue.
Does your state 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 antidepressant drugs in children.
62 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
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 state have a documented program in place to manage and monitor the
appropriate use of mood stabilizing drugs in children?
Yes
No
If “Yes,” please continue.
a. Does your state manage and monitor:
Only children in foster care under 18 y.o.
All children including foster care under 18 y.o.
Other, please explain.
b. Does your state have edits in place to monitor (check all that apply):
Child’s age
Dosage
Indication
Polypharmacy
Other, please explain.
63 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
c. Please briefly explain the specifics of your documented mood stabilize r
monitoring program(s).
If “No,” please continue.
d. Does your state 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.
ANTIANXIETY/SEDATIVES
7. Does your state have a documented program in place to manage and monitor the
appropriate use of antianxiety/sedative drugs in children?
Yes
No
If “Yes,” please continue.
a. Does your state either manage or monitor:
Only children in foster care under 18 y.o.
All children including foster care under 18 y.o.
Other, please explain.
64 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
b. Does your state have edits in place to monitor (check all that apply):
Child’s age
Dosage
Indication
Polypharmacy
Other, please explain.
c. Please briefly explain the specifics of your documented antianxiety/sedative
monitoring program(s).
If “No,” please continue.
d. Does your state plan on implementing an antianxiety/sedative monitoring
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.
65 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
IX. INNOVATIVE PRACTICES
1. Does your state participate in any demonstrations or have any waivers to allow
importation of certain drugs from Canada or other countries that are versions of FDAapproved drugs for dispensing to Medicaid beneficiaries?
Yes, please explain.
No
2. Summary 5 – 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).
66 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
X. MANAGED CARE ORGANIZATIONS (MCOs)
1. How many MCOs are enrolled in your state Medicaid program?
MCO(s) (Insert the number of MCOs in the space provided including
0 if none)
If “Zero” or “None”, please skip the rest of this section.
2. Is your pharmacy program included in the capitation rate (carved in)?
Yes
No
Partial
If “Partial,” please check what categories of medications are carved out of
managed care benefits and handled by your FFS program:
Mental health medications
MAT
Opioids
Clotting factors
Other, please specify the drug categories.
3. Contract updates between state and MCOs addressing DUR provisions in Section 1004
Support for Patients and Communities Act are required based on 1902(oo). If
covered outpatient drugs are included in an MCO’s covered benefit package, has the
state updated their MCOs’ contracts for compliance with Section 1004 of the
SUPPORT for Patients and Communities Act?
Yes, contracts are updated to address each provision. Please specify effective date:
No, contracts are not updated, please explain why not.
67 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
a. Is the state complying with federal law and monitoring MCO compliance on
the SUPPORT for Patients and Communities Act provisions?
Yes, state is complying with federal law and monitoring MCO compliance
on SUPPORT for Patients and Communities Act provisions. Please
explain monitoring activities.
No, please explain why not.
4. Does the state use a single PBM/PBA if the MCO has a drug benefit?
Yes
No
N/a
5. Does the state set requirements for the MCO’s pharmacy benefit (i.e. same
preferred drug list, same ProDUR/RetroDUR)?
Yes
No
If “Yes,” please continue.
a. Please check all requirements that apply below:
Formulary Reviews
Same PDL
Same ProDUR
Same RetroDUR
No state PDL
b. Please briefly explain your policy.
68 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
If “No,” does your state plan to set standards in the future?
Yes
No, please explain.
6. Is the RetroDUR program operated by the state, by the MCOs or does your state use
a combination of state interventions as well as individua l MCO interventions?
State operated
MCO operated
State uses a combination of state interventions
interventions
as well as individual MCO
7. Indicate how the state oversees the FFS and MCO RetroDUR programs? Please
explain oversight process.
8. How does the state ensure MCO compliance with DUR requirements described
in Section 1927(g) of the Act and 42 C.F.R part 456, subpart K?
9. Did all of your managed care plans submit their DUR reports?
Yes
No, please explain why not.
69 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
70 | P a g e
FFY 2024 MEDICAID FEE-FOR-SERVICE (FFS)
DRUG UTILIZATION REVIEW (DUR) ANNUAL SURVEY
XI. EXECUTIVE SUMMARY
Executive Summary should provide a brief overview of your program. It should describe
FFY 2024 highlights of the program, FFS initiatives, improvements, program oversight of
managed care partners when applicable, and statewide (FFS and MCO) initiatives.
71 | P a g e
| File Type | application/pdf |
| File Title | FFY 2021 MEDICAID FEE-FOR-SERVICE (FFS) |
| Subject | 171 |
| Author | MICHAEL FORMAN |
| File Modified | 2024-07-02 |
| File Created | 2024-07-02 |