REDLINE: Abbreviated MCO Surveys

FFY 2024 MEDICAID MANAGED CARE ORGANIZATION (MCO)
DRUG UTILIZATION REVIEW (DUR) ANNUAL ABBREVIATED SURVEY

ABOUT THE SURVEY
42 C.F.R. § 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. While states
have the ability to exclude (or “carve out”) subsets of Medicaid benefits from their MCO contracts, it is
typical that an MCO that does not cover the pharmacy benefit (that is, pay for covered outpatient drugs
(CODs) dispensed from a pharmacy) will still be responsible for covering CODs administered in a
doctor’s office and/or outpatient hospital or clinic. 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, 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. This
abbreviated version of the MCO survey is for MCOs that have pharmacy benefits covered through the Fee
-For-Service (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.
CMS does not edit State responses; therefore, what is submitted will be what is
posted on Medicaid.gov. This material is also utilized for composing the annual report to Congress.
Pursuant to 42 C.F.R. § 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 2012. 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.
has been removed from this survey.

Confidential and proprietary information

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

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and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect

the data needed,
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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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:
Position Title:
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 Act covered outpatient drugs (CODs) included in Fee-forService (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 ye s, completion of the remaining survey is voluntary--------------------------

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



Drugs administered during an outpatient hospital stay



Emergency Departments (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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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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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 medical benefit.
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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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, please explain why not.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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 Revie w
(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 misuse or abuse of controlled substances?
Yes
No
If “No”, skip to question 3.
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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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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 why not..

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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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 why not..

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.

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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, pre scribers, and pharmacy
providers?
Yes, please explain your program for FWA of non-controlled substances.

No, please explain why not.

6. Briefly explain the MCOs objectives and scope of responsibility between DUR and SUR
functions as they relate to FWA. Additionally, explain how the MCO maintains separation
between fraud and abuse and educational activities. (Character limit 1000)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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B. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)

1. Does your MCO 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.
a. Please check all applicable ways your MCO accesses the PDMP database.
 Receive PDMP data
 Direct access to the database
i.

If “Receive PDMP data,” please specify how often. Check all
that apply.





ii.

Daily
Weekly
Monthly
Other, please specify. ____________

If “Direct access to the database,” please specify how. Check
all that apply.





Can query by client (beneficiary)
Can query by prescriber
Can query by dispensing entity

b. Please explain how your MCO applies this information to help control
FWA of controlled substances.

c. Does your State also have access to contiguous States’ PDMP information?

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


Yes
No

2. 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 12month 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 data that prevent the program from being utilized the way it
was intended to be to curb FWA?



Yes, please explain the barriers (e.g., lag time in
prescription data being submitted, prescribers not
accessing, pharmacists unable to view prescription
history before filling script).



No
3. 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
Public notice
Provider manual
RetroDUR communication
Other, please explain.

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

No, please explain.
a.

Has your MCO specified protocols for prescribers checking the
PDMP?



Yes, please explain.



No

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b. 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

c. 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.

If “Yes,” does your MCO require the provider to submit, upon request,
documentation to the State?




Yes
No, please explain.

4. Have any changes occurred to your State’s PDMP during this reporting period that
improved or detracted from the Medicaid program’s ability to access PDMP data?



Yes, please explain.



No

5. In this reporting period, have there been any data or privacy breaches of the PDMP or
PDMP data?
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 Yes
 No

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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 to monitor 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
If “Yes,” please check all that apply.



Automated retrospective claim reviews



Educational programs
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

Titration programs



Peer to peer assistance

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

No, please explain why not.

4. Does your MCO coordinate with the entity that provides the drug benefits to monitor
opioids and sedatives being used concurrently?
Yes
If “Yes,” please check all that apply.



Automated retrospective claim reviews



Educational programs



Titration programs



Peer to peer assistance

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No, please explain why not.

5. Does your MCO coordinate with the entity that provides the drug benefits to monitor
opioids and antipsychotics being used concurrently?
Yes
If “Yes,” please check all that apply.



Automated retrospective claim reviews



Educational programs



Titration programs



Peer to peer assistance

No, please explain why not.

6. Does your MCO 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.

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If “Yes,” please check all that apply
Automated retrospective claim reviews
Provider education
If “Yes,” automated retrospective reviews and/or provide r education, please continue.
a. Please indicate how often:
Monthly
Quarterly
Semi-Annually
Annually
Ad hoc
Other, please specify.

b. Please explain the nature and scope of reviews 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?

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Yes, when does your MCO plan on implementing?

No, please explain.

7. Does your program develop and provide prescribers with pain management or opioid
prescribing guidelines?
Yes
No
If “Yes”, please check all that apply.
Your prescribers are referred to the Center for Disease Control
(CDC) 2022 Clinical Practice Guideline for Prescribing Opioids
for 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 opioid reversal agents 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. PSYCHOTROPIC MEDICATION
ANTIPSYCHOTICS
1. Does your MCO coordinate with the entity that provides the drug benefit to manage and
monitor the appropriate use of antipsychotic drugs in children?
Yes
No
Covered through the FFS benefit
If “Yes”, please continue.
If “No” or “Covered through the FFS benefit”, skip to question 1.c.
a. Does your MCO 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. Please briefly explain the specifics of your antipsychotic monitoring program(s).

c. 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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2. Does your MCO 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 communitybased services (as defined in section 9817(a)(2)(B) of Public Law 117–2)?
Yes
No
If “Yes,” please continue.
a. Does your MCO have edits in place to monitor (check all that apply):






Dosage
Indication
Polypharmacy
Other, please explain.

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

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



Yes, please specify when you plan on implementing a program.

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

No, please explain why you will not be implementing a program.

3. Does your MCO 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.
a. Does your MCO 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 MCO does not monitor all of the above, please explain why not.

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



Dosage
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
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Indication

Polypharmacy
Other, please explain.

c. Please briefly explain the specifics of your documented antipsychotic monitoring
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.

No, please explain why you will not be implementing a program.

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monitor the appropriate use of antipsychotic drugs in children.
STIMULANTS
4. Does your MCO coordinate with the entity that provides the drug benefit to manage and
monitor the appropriate use of stimulant drugs in children?
Yes
No
Covered through the FFS benefit
If “Yes”, please continue.
If “No” or “Covered through the FFS benefit”, skip to question 2.c.
a. Does your MCO 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. Please briefly explain the specifics of your documented stimulant monitoring
program(s).

c. 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.

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

ANTIDEPRESSANTS/MOOD STABILIZERS/ANTIAXIETY/SEDATIVES
5. Does your MCO coordinate with the entity that provides the drug benefit to manage and
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
Covered through the FFS benefit
If “Yes”, please continue with questions 3.a and 3.b.
If “No” or “Covered through the FFS benefit”, skip to question 3.c.
a. Does your MCO manage and monitor
Only children in foster care under 18 y.o.
All children including foster care under 18 y.o.

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Other, please explain.

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

c. 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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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 Practice s
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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