CMS-R-153 MCO Medicaid Annual Report

MEDICAID MANAGED CARE ORGANIZATION

MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT

FEDERAL FISCAL YEAR 2019

42 CFR 438.3(s)(4) and (5) require that each Medicaid managed care organization (MCO) must operate a drug utilization review (DUR) program that complies with the requirements described in Section 1927 (g) of the Social Security Act (the Act) and submit an annual report on the operation of its DUR program activities. Such reports are to include: descriptions of the nature and scope of the prospective and retrospective DUR programs; a summary of the interventions used in retrospective DUR and an assessment of the education program; a description of DUR Board activities; and an assessment of the DUR program’s impact on quality of care.

This report covers the period October 1, 2018 to September 30, 2019. 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 CMS via email at: CMSDUR@cms.hhs.gov.

PRA Disclosure Statement This mandatory information collection (section 4401 of the Omnibus Budget Reconciliation Act of 1990 and section 1927(g) of the Social Security Act) is necessary to establish patient profiles in pharmacies, identify problems in prescribing and/or dispensing, determine each program’s ability to meet minimum standards required for Federal financial participation, and ensure quality pharmaceutical care for Medicaid patients. State Medicaid agencies that have prescription drug programs are required to perform prospective and retrospective DUR in order to identify aberrations in prescribing, dispensing and/or patient behavior. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this information collection request is 0938-0659 (Expires: TBD). 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.

This survey is for viewing purposes only and not for submission. Survey submission will be performed through the CMS Medicaid Drug Program (MDP) System available March 1, 2020. As the surveys are being generated through our MDP System, formatting and question access may differ slightly to the attachment provided.

MEDICAID MANAGED CARE ORGANIZATION

MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT

FEDERAL FISCAL YEAR 2018

1. DEMOGRAPHIC INFORMATION

State Abbreviation: _______

MCO Name: ____________________________________________________________

(Please note: Name above must match name entered in MDP DUR system)

Program Type:

If other, please specify.

Medicaid MCO Information

Identify the MCO person responsible for DUR Annual Report Preparation.

First Name: ________________________________________________

Last Name: ________________________________________________

Email Address: ________________________________________________

Area Code/Phone Number: ________________________________________________

1. On average, how many Medicaid beneficiaries are enrolled monthly in your MCO for this Federal Fiscal Year?

_____ Beneficiaries

2. PROSPECTIVE DUR (ProDUR)

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

• State-operated

• 
  Contractor, please identify by name.

• 
  Other organization, please identify by name.

2. Identify ProDUR criteria source.

• First Data Bank

• Medi-Span

• Molina

• 
  Other, please specify.

3. Are new ProDUR criteria approved by the DUR board?

• Yes

• 
  No, please explain

1. If yes, who reviews your new ProDUR criteria?

• MCO’s DUR Board

• FFS agency DUR Board

• 
  Other, please explain.

4. When the pharmacist receives a level-one 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

• No

• 
  Partial, please explain.

5. Do you receive and review follow-up periodic reports providing individual pharmacy provider DUR alert override activity in summary and/or in detail?

• Yes

• No

1. How often?

• Monthly

• Quarterly

• Annually

• Other

2. If you receive reports, do you follow up with those providers who routinely override with interventions?

• Yes

• 
  No, please explain.

If the answer to question 5b is “No,”skip to question 6.

If the answer to question 5b is “Yes,” please continue below.

By what method do you follow up?

• Contact Pharmacy

• Refer to Program Integrity for Review

• 
  Other, please explain.

6. Early Refill

1. At what percent threshold do you set your system to edit?

Non-controlled drugs:

­­%

Schedule II controlled drugs:

%

Schedule III through V controlled drugs:

%

2. For non-controlled drugs

When an early refill message occurs, does your MCO require prior authorization?

• Yes

• No

If the answer to question 6b is “Yes,” who obtains authorization?

• Pharmacist

• Prescriber

• Either

If the answer to question 6b is “No,” can the pharmacist override at the point of service?

• Yes

• No

3. For controlled drugs

When an early refill message occurs, does your MCO require prior authorization?

• Yes

• No

d. If the answer to question 6c is “Yes,” who obtains authorization?

• Pharmacist

• Prescriber

• Either

If the answer to question 6c is “No,” can the pharmacist override at the point of service?

• Yes

• No

7. When the pharmacist receives an early refill DUR alert message that requires the pharmacist’s review, does your state’s policy allow the pharmacist to override for situations such as:

1. Lost/stolen Rx

• Yes

• No

2. Vacation

   • Yes

   • No

3. 
   Other, please explain.

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

• Yes

• No

1. 
   If “Yes,” please explain your edits.

2. If “No,” do you plan to implement this edit?

• Yes

• No

9. Does the MCO have any policy prohibiting the auto-refill process that occurs at the POS (i.e. must obtain beneficiary’s consent prior to enrolling in the auto-refill program)?

• Yes

• No

10. Does your MCO have any policy that provides for the synchronization of prescription refills (i.e. if the patient wants and pharmacy provider permits the patient to obtain non-controlled, chronic medication refills at the same time, the state would allow this to occur to prevent the beneficiary from making multiple trips to the pharmacy within the same month)?

• Yes

• No

11. For drugs not on your MCO’s formulary, does your MCO have a documented process (i.e. prior authorization) in place, so that the Medicaid beneficiary or the Medicaid beneficiary’s prescriber may access any covered outpatient drug when medically necessary?

• Yes

• No

If “Yes,” what is the preauthorization process?

If “No,” please explain why there is not a process for the beneficiary to access a covered outpatient drug when it is medically necessary.

12. Please list the requested data in each category in Table 1 – Top Drug Claims Data Reviewed by the DUR Board below.

Table 1: Top Drug Claims Data Reviewed by the DUR Board

Column 1 Top 10 Prior Authorization (PA) Requests by Drug Name	Column 2 Top 10 Prior Authorization (PA) Requests by Drug Class	Column 3 Top 5 Claim Denial Reasons Other Than Eligibility (i.e. Quantity Limits, Early Refill, PA, Therapeutic Duplications, Age Edits)	Column 4 Top 10 Drug Names by Amount Paid	Column 5 % of Total Spent for Drugs by Amount Paid From data in Column 4, determine the % of total drug spend.	Column 6 Top 10 Drug Names by Claim Count	Column 7 Drugs by Claim Count % of Total Claims From data in Column 6, determine the % of total claims.
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%

3. RETROSPECTIVE DUR (RetroDUR)

1. Does your MCO utilize the same DUR Board as the state Fee-For-Service (FFS) agency or does your MCO have its own DUR Board?

• Same DUR Board as FFS agency

• MCO has its own DUR Board

• 
  Other, please explain.

Identify the entity, by name and type, that performed your RetroDUR activities during the time period covered by this report (company, academic institution, other organization, or indicate if your MCO executed its own RetroDUR activities).

2. Who reviews and approves the RetroDUR criteria?

• State DUR Board

• MCO DUR Board

• 
  Other, please explain.

3. Has your MCO included, a year end summary of the Top 10 problem types for which educational interventions were taken?

• Yes

• No

Upload Attachment 1- Retrospective DUR Educational Outreach Summary

See attachment naming instructions.

4. DUR BOARD ACTIVITY

1. Has your MCO included a brief summary of DUR Board activities during the time

period covered by this report?

• Yes

• No

Summary of DUR Board Activities

The summary should be a brief descriptive report on DUR Board activities during the fiscal year reported.

• Indicate the number of DUR Board meetings held

• List additions/deletions to DUR Board approved criteria

1. For prospective DUR, list problem type/drug combinations added or deleted

2. For retrospective DUR, list therapeutic categories added or deleted

• Describe Board policies that establish whether and how results of prospective DUR screening are used to adjust retrospective DUR screens.

• Describe policies that establish whether and how results of retrospective DUR screening are used to adjust prospective DUR screens

• Describe DUR Board involvement in the DUR education program (i.e. newsletters, continuing education, etc.)

• Describe policies adopted to determine mix of patient or provider specific intervention types (i.e. letters, face-to-face visits, increased monitoring).

Upload Attachment 2 - Summary of DUR Board Activities

See attachment naming instructions.

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

• Yes

• No

If the answer to question 2 is “Yes,” please continue with questions a) and b) below.

1. Have you performed an analysis of the program’s effectiveness?

• 
  Yes, please provide a brief summary of your findings.

• No

2. Is your DUR Board involved with this program?

• Yes

• No

If the answer to question 2 is “No,” are you planning to develop and implement a program?

• Yes

• No

5. PHYSICIAN ADMINISTERED DRUGS

The Deficit Reduction Act required collection of NDC numbers for covered outpatient physician administered drugs. These drugs are paid through the physician and hospital programs. Has your pharmacy system been designed to incorporate this data into your DUR criteria for:

1. ProDUR?

• Yes

• No

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

• Yes

• No

2. RetroDUR?

• Yes

• No

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

• Yes

• No

6. GENERIC POLICY AND UTILIZATION DATA

1. Has your MCO included a brief description of policies that may impact generic utilization percentage?

• Yes

• No

Upload Attachment 3 - Generic Drug Substitution Policies

See attachment naming instructions.

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 MCO have a more restrictive requirement?

• Yes

• No

If “Yes,” check all that apply:

• Require that a MedWatch Form be submitted

• Require the medical reason(s) for override accompany the prescription

• Prior authorization is required

• Prescriber must indicate “Brand Medically Necessary” on the prescription

• 
  Other, please explain.

Complete Table 2 – Generic Drug Utilization Data using the following Computation Instructions.

Computation Instructions Key

Single Source (S) – Drugs having an FDA New Drug Application (NDA), and there are no generic alternatives available on the market.

Non-Innovator Multiple-Source (N) – Drugs that have an FDA Abbreviated New Drug Application (ANDA), and generic alternatives exist on the market.

Innovator Multiple-Source (I) – Drugs which have an NDA and no longer have patent exclusivity.

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

Table 2: Generic Drug Utilization Data

	Single Source (S) Drugs	Non-Innovator (N) Drugs	Innovator Multi- Source (I) Drugs

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. This file will be made available from CMS to facilitate consistent reporting across states with this data request.

3. Indicate the generic utilization percentage for all covered outpatient drugs paid during

this reporting period, using the computation instructions in Table 2 – Generic Utilization Data.

Number of Generic Claims ______________

Total Number of Claims ______________

Generic Utilization Percentage ______________

7. FRAUD, WASTE, AND ABUSE DETECTION

1. LOCK-IN or PATIENT REVIEW AND RESTRICTION PROGRAMS

1. Do you have a documented process in place that identifies potential fraud or abuse of controlled drugs by beneficiaries?

• Yes

• No

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

• Deny claims and require prior authorization

• Refer to Lock-In Program

• Refer to Program Integrity Unit

• 
  Other (i.e. SURS, Office of Inspector General), please explain.

2. Do you have a Lock-In program for beneficiaries with potential misuse or abuse of controlled substances?

• Yes

• No

If the answer to question 2 is “No,” skip to question 3.

If the answer to question 2 is “Yes,” please continue.

1. What criteria does your MCO use to identify candidates for Lock-In? Check all that apply:

• Number of controlled substances (CS)

• Different prescribers of CS

• Multiple pharmacies

• Number days’ supply of CS

• Exclusivity of short acting opioids

• Multiple ER visits

• PDMP data

• Same FFS state criteria is applied

• 
  Other, please explain.

2. Do you have the capability to restrict the beneficiary to:

1. Prescriber only

• Yes

• No

2. Pharmacy only

• Yes

• No

3. Prescriber and pharmacy only

• Yes

• No

3. What is the usual Lock-In time period?

• 12 months

• 18 months

• 24 months

• 
  Other, please explain.

4. On average, what percentage of your Medicaid MCO population is in Lock-In status annually?

­­%

3. Do you have a documented process in place that identifies possible fraud or abuse 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

• Refer to the appropriate Medical Board

• 
  Other, please explain why not.

4. Do you have a documented process in place that identifies potential fraud or abuse 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

• Refer to the Board of Pharmacy

• 
  Other, please explain.

5. Do you have a documented process in place that identifies and/or prevents potential fraud or abuse of non-controlled drugs by beneficiaries?

   • 
     Yes, please explain your program for fraud, waste or abuse of non-controlled substances.

• No

If No, please explain why not.

2. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)

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

   • Yes, please explain your program for fraud, waste or abuse of non-controlled substances.

• No

• No, the state does not have a PDMP

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

   • Yes

   • No

If “Yes,” are there barriers that hinder your MCO from fully accessing the PDMP that prevent the program from being utilized the way it was intended to be to curb abuse?

• 
  Yes, please explain the barriers that exist.

• No

1. Does your MCO have access to border states’ PDMP information?

   • Yes

   • No

3. PAIN MANAGEMENT CONTROLS

1. Does your MCO obtain the DEA Active Controlled Substance Registrant’s File in order to identify prescribers not authorized to prescribe controlled drugs?

• Yes

• No

If the answer to question 1 is “No,” skip to question 2.

If the answer to question 1 is “Yes,” please continue.

1. Do you apply this DEA file to your ProDUR POS edits to prevent unauthorized prescribing?

• Yes

• No

If “Yes,” please explain how information is applied.

2. If “No,” do you plan to obtain the DEA Active Controlled Substance Registrant’s file and apply it to your POS edits?

• Yes

• No

2. Do you apply this DEA file to your RetroDUR reviews?

• 
  Yes, please explain how it is applied.

• No

3. Do you have a measure (i.e. prior authorization, quantity limits) in place to either monitor or manage the prescribing of methadone for pain management?

• Yes

• 
  No, please explain why you do not have a measure in place to either manage or monitor the prescribing of methadone for pain management.

4. OPIOIDS

1. Do you currently have a POS edit in place to limit the quantity dispensed of an initial opioid prescription?

• Yes for all opioids

• Yes for some opioids

• No for all opioids

Please explain answers above.

1. Is there more than one quantity limit for various opioids?

• Yes

• No

If there is more than one quantity limit for the various opioids please explain.

2. What is the maximum number of days allowed for an initial opioid prescription?

____ # of days

• Yes for some opioids

• Yes for all opioids

• No

3. If you have different days allowed for the initial limit for the various opioids, please explain.

2. For subsequent prescriptions, do you have POS edits in place to limit the quantity dispensed of short-acting opioids?

• Yes

• No

1. If “Yes,” what is your maximum days’ supply per prescription limitation?

• 30 day supply

• 90 day supply

  

• Other, please explain.

2. 
   If “No,” why not?

3. Do you currently have POS edits in place to limit the quantity dispensed of long-acting opioids?

• Yes

• No

1. If “Yes,” what is your maximum days’ supply per prescription limitation?

• 30 day supply

• 90 day supply

• Other, please explain.

2. 
   If “No,” why not?

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

• Yes

• No

1. If “Yes,” please check all that apply:

• Pharmacist override

• Deny claim and require PA

• Intervention letters

• Morphine equivalent daily dose (MEDD) program

• Step therapy or Clinical criteria

• Requirement that patient has a pain management contract or Patient-Provider agreement

• Requirement that prescriber has an opioid treatment plan for patients

• Require documentation of urine drug screening results

• Other, please specify

Please provide details on these opioid prescribing controls are in place.

b) If the answer to (number 4) above is “No,” please explain what you do in lieu of the above or why you do not have measures in place to either manage or monitor the prescribing of opioids.

5. Do you have an automated claim retrospective reviews to monitor quantity dispensed and days’ supply of opioid prescriptions dispensed?

• Yes

  
  

• No

If “Yes,” please explain nature and scope of reviews.

If “No,” please explain why not.

6. Do you have POS edits and or automated claim retrospective reviews to monitor duplicate therapy of opioid prescriptions dispensed?

• Yes

• Yes automated claim retrospective reviews

  
  

• No

If “Yes,” please explain scope and nature.

If “No,” please explain why not.

7. Do you have POS edits and or automated claim retrospective reviews to monitor early refills of opioid prescriptions dispensed? (check all those that apply)

• Yes POS edits

• Yes retrospective reviews

  
  

• No

If “Yes,” please explain scope and nature of reviews and edits in place.

If “No,” please explain why not.

8. Do you currently have POS edits in place or a retrospective claims review to monitor opioids and benzodiazepines being used concurrently?

• Yes POS edits

• Yes retrospective reviews

• No

If “Yes,” please explain reviews and edits in place.

If “No,” please explain why not.

9. Do you currently have POS edits in place or a retrospective claims review to monitor opioids and sedatives being used concurrently?

• Yes POS edits

• Yes Retrospective claim reviews

• No

If “Yes,” please explain.

If “No,” please explain why not.

10. Do you currently have POS edits in place or a retrospective claims review to monitor opioids and antipsychotics being used concurrently?

• Yes, POS edits are in place

• Yes, Retrospective claims reviews are in place

• No,

If “Yes,” please explain.

If “No,” please explain why not.

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

• Yes POS edits

• Yes retroDUR activity

• No

1. If RetroDUR and/or provider education reviews are performed “Yes,” please indicate how often.

• Monthly

• Quarterly

• Semi-Annually

• Annually

• Other please specify:

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

2. If the answer to (number 11) above is “No,” do you plan on implementing a RetroDUR activity and/or provider education in regard to beneficiaries with a diagnosis history of OUD or opioid poisoning in the future?

• Yes

If “Yes,” when do you plan on implementing?

• No

If “No,” please explain why not.

12. Does your state Medicaid agency develop and provide prescribers with pain management or opioid prescribing guidelines?

• Yes

• No

Please check:

• Your state Medicaid agency refers prescribers to the CDC’s Guideline for Prescribing Opioids for Chronic Pain

• Other guidelines

• No guidelines are offered

Please identify “other” or “referred” guidelines.

13. Do you 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

• No

If “Yes,” please explain.

5. MORPHINE EQUIVALENT DAILY DOSE (MEDD)

14. Have you set recommended maximum morphine equivalent daily dose measures?

• Yes

• No

1. If “Yes,” what is your maximum morphine equivalent daily dose limit in milligrams?

• 50 MME

• 70 MME

• 80 MME

• 90 MME

• 100 MME

• Other: Please specify: _______ mg per day

2. 
   If “Yes” please explain nature and scope of dose limit (i.e. who does the edit apply to? Does the limit apply to all opioids? Are you in the process of tapering patients to achieve this limit)?

3. If “No,” please explain the measure or program you utilize.

15. Do you provide information to your prescribers on how to calculate the morphine equivalent daily dosage or do you provide a calculator developed elsewhere?

• Yes

• No

Please name the developer of the calculator.

If “Yes,” how is the information disseminated?

• Website

• Provider notice

• Educational seminar

• Other, please explain.

16. Do you have an edit in your POS system that alerts the pharmacy provider that the morphine equivalent daily dose prescribed has been exceeded?

• Yes

• No

If “Yes,” do you require prior authorization if the MEDD limit is exceeded?

• Yes

• No

17. Do you have automated retrospective claim reviews to monitor total daily dose (MME) of opioid prescriptions dispensed?

• 
  Yes, please explain.

• 
  No, please explain why not.

6. BUPRENORPHINE, NALOXONE, BUPRENORPHINE/NALOXONE COMBINATIONS and METHADONE for OPIOID USE DISORDER (OUD)

1. Does your agency 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

• 16 mg

• 24 mg

• Other, please explain.

2. What are your limitations on the allowable length of this treatment?

• 6 months

• 12 months

• No limit

• Other, please explain.

3. Do you require that the maximum mg per day allowable be reduced after a set period of time?

• Yes

• No

1. If “Yes,” what is your reduced (maintenance) dosage?

• 8 mg

• 12 mg

• 16 mg

• Other, please explain.

2. If “Yes,” what are your limitations on the allowable length of the reduced dosage treatment?

• 6 months

• 12 months

• No limit

• Other, please explain.

4. Do you have at least one buprenorphine/naloxone combination product available without prior authorization?

• Yes

• No

5. Do you currently have edits in place to monitor opioids being used concurrently with any buprenorphine drug or any form of MAT?

• Yes

• No

• Other, please explain.

If “Yes,” can the POS pharmacist override the edit?

• Yes

• No

6. Do you have at least one naloxone opioid overdose product available without prior authorization?

• Yes

• No

7. Do you retrospectively monitor and manage appropriate use of naloxone to persons at risk of overdose

• Yes

• No

8. Does your state board of pharmacy and/or state Medicaid agency allow pharmacists to dispense naloxone prescribed independently or by collaborative practice agreements, standing orders, or other predetermined protocols?

• Yes

If “Yes”, please explain if a process is in place.

• No

9. Does your state agency cover Methadone for a substance use disorder (i.e. Methadone Treatment Center)?

• Yes

• No

7. ANTIPSYCHOTICS /STIMULANTS

ANTIPSYCHOTICS

1. Do you currently have restrictions in place to limit the quantity of antipsychotics?

• Yes

• No

If restriction is other than quantity limit, please explain.

2. Do you have a documented program in place to either manage or monitor the appropriate use of antipsychotic drugs in children?

• Yes

• No

1. If “Yes,” do you either manage or monitor:

• Only children in foster care

• All children

• Other, please explain.

2. If “Yes,” do you have edits in place to monitor (check all that apply):

• Child’s Age

• Dosage

• Polypharmacy

• Other

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

d) If you do not have an antipsychotic monitoring program in place, do you plan on implementing a program in the future?

• Yes

• No

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

STIMULANTS

3. Do you currently have restrictions in place to limit the quantity of stimulants?

• Yes

• No

4. Do you have a documented program in place to either manage or monitor the appropriate use of stimulant drugs in children?

• Yes

• No

a) If “Yes,” do you either manage or monitor:

• Only children in foster care

• All children

• Other, please explain.

b) If “Yes,” do you have edits in place to monitor (check all that apply):

• Child’s Age

• Dosage

• Polypharmacy

3. Please briefly explain the specifics of your documented stimulant monitoring

program(s).

4. If you do not have a documented stimulant monitoring program in place, do you plan on implementing a program in the future?

• Yes

If “Yes,” when?

• No

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

8. INNOVATIVE PRACTICES

Have you developed any innovative practices during the past year which you have included in Attachment 6 – Innovative Practices (i.e. Substance Use Disorder, Hepatitis C, Cystic Fibrosis, MEDD, Value Based Purchasing)?

• Yes

• No

9. E-PRESCRIBING

1. Does your MMIS or pharmacy vendor have a portal to electronically provide patient drug history data and pharmacy coverage limitations to a prescriber prior to prescribing upon inquiry?

• Yes

• No

1. If “Yes,” do you have a methodology to evaluate the effectiveness of providing drug information and medication history prior to prescribing?

• Yes

• No

2. If “Yes,” please explain the evaluation methodology in Attachment 7 – E-

Prescribing Activity Summary.

3. If the answer to (number 1) above is “No,” are you planning to develop this

capability?

• Yes

• No

2. Does your system use the NCPDP Origin Code that indicates the prescription source?

• Yes

• No

10. MANAGED CARE ORGANIZATIONS (MCOs)

1. How many MCOs are enrolled in your state Medicaid program?

____________MCO(s) (Insert number of MCOs in the blank 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 specify the drug categories that are carved out.

3. Does the state set requirements for the MCO’s pharmacy benefit (i.e. same PDL, same ProDUR/RetroDUR)?

• Yes

• No

1. If “Yes,” please check all requirements that apply below:

• Formulary Reviews

• Same PDL

• Same ProDUR

• Same RetroDUR

2. If “Yes,” please briefly explain your policy.

3. If “No,” do you plan to set standards in the future?

• Yes

• No

4. Did all of your managed care plans submit their DUR reports?

• Yes

• No

If “No,” please explain why.

11. EXECUTIVE SUMMARY – Attachment 8 – Executive Summary

MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT

INSTRUCTIONS: Nomenclature Format for Attachments

States: Please use this standardized format for naming attachments.

ATT#-FFY-State Abbrev-Abbreviated Report name (NO SPACES!) Example for

Arizona: (each state should insert their 2 letter state code)

Attachments:

ATT1-20_ _-AZ-POCCR (Pharmacy Oral Counseling Compliance Report)

ATT2-20_ _-AZ-REOS (RetroDUR Educational Outreach Summary)

ATT3-20_ _-AZ-SDBA Summary of DUR Board Activities)

ATT4-20_ _-AZ-GDSP (Generic Drug Substitution Policies)

ATT5-20_ _-AZ-CSCAM (Cost Savings/Cost Avoidance Methodology)

ATT6-20_ _-AZ-IPN (Innovative Practices Narrative)

ATT7-20_ _-AZ-EAS (E-Prescribing Activity Summary)

ATT8-20_ _-AZ-ES (Executive Summary)

EXPLANATION FOR ATTACHMENTS AND TABLES

ATTACHMENT 1 – PHARMACY ORAL COUNSELING COMPLIANCE REPORT

This attachment reports the monitoring of pharmacy compliance with all prospective DUR requirements performed by the State Medicaid Agency, the State Board of Pharmacy, or other entity responsible for monitoring pharmacy activities. If the State Medicaid Agency itself monitors compliance with these requirements, it may provide a survey of a random sample of pharmacies with regard to compliance with the Omnibus Budget Reduction Act (OBRA) of 1990 prospective DUR requirement. This report details state efforts to monitor pharmacy compliance with the oral counseling requirement. This attachment should describe in detail the monitoring efforts that were performed and how effective these efforts were in the fiscal year reported.

ATTACHMENT 2 – RETROSPECTIVE EDUCATIONAL OUTREACH SUMMARY

This is a year-end summary report on RetroDUR screening and educational interventions. The year-end summary reports should be limited to the TOP 10 problems with the largest number of exceptions. The results of RetroDUR screening and interventions should be included.

ATTACHMENT 3 – SUMMARY OF DUR BOARD ACTIVITIES

This summary should be a brief descriptive report on DUR Board 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.

1. For prospective DUR, list problem type/drug combinations added or deleted.

2. For retrospective DUR, list therapeutic categories added or deleted.

• Describe Board policies that establish whether and how results of prospective DUR screening are used to adjust retrospective DUR screens. Also, describe policies that establish whether and how results of retrospective DUR screening are used to adjust prospective DUR screens.

• Describe DUR Board involvement in the DUR education program (i.e. newsletters, continuing education, etc.) Also, describe policies adopted to determine mix of patient or provider specific intervention types (i.e. letters, face-to-face visits, increased monitoring).

ATTACHMENT 4 – GENERIC DRUG SUBSTITUTION POLICIES

Please report any factors that could affect your generic utilization percentage and include any relevant documentation.

ATTACHMENT 5 – COST SAVINGS/COST AVOIDANCE METHODOLOGY

Include copy of program evaluations/cost savings estimates prepared by state or contractor noting methodology used.

ATTACHMENT 6 – INNOVATIVE PRACTICES

Please describe in detailed narrative form 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 prior authorizations, continuing education programs).

ATTACHMENT 7 – E-PRESCRIBING ACTIVITY SUMMARY

Please describe all development and implementation plans/accomplishments in the area of e-prescribing. Include any evaluation of the effectiveness of this technology (i.e. number of prescribers e-prescribing, percent e-prescriptions to total prescriptions, relative cost savings).

ATTACHMENT 8 – EXECUTIVE SUMMARY

Suggest to include a general overview and summary of program highlights from 2018 as well as objectives, tools and outcomes of initiatives accomplished in 2018 as well as goals for 2019. Suggest including a summary of oversight of program and MCOs.

TABLE 1 – TOP DRUG CLAIMS DATA REVIEWED BY THE DUR BOARD

List the requested data in each category in the chart below.

Column 1 – Top 10 Prior Authorization (PA) Requests by Drug Name

Column 2 – Top 10 PA Requests by Drug Class

Column 3 – Top 5 Claim Denial Reasons other than eligibility , or data validity edits like invalid birthday or drug not rebatable (i.e. Quantity Limits, Early Refill, PA, Therapeutic Duplications, Age Edits)

Column 4 – Top 10 Drug Names by Amount Paid

Column 5 – From Data in column 4, Determine the Percentage of Total Drug Spend

Column 6 – Top 10 Drug Names by Claim Count

Column 7 – From Data in Column 6, Determine the Percentage of Total Claims

Top 10 PA Requests By Drug Name	Top 10 PA Requests By Drug Class	Top 5 Claim Denial Reasons (i.e. QL, Early Refill, PA, Duplication)	Top 10 Drug Names by Amount Paid	% of Total Spent for Drugs by Amount Paid	Top 10 Drug Names by Claim Count	Drugs By Claim Count % of Total Claims
		XXXXXXXXXXX
		XXXXXXXXXXX
		XXXXXXXXXXX
		XXXXXXXXXXX
		XXXXXXXXXXX

TABLE 2 – GENERIC UTILIZATION DATA

Please provide the following utilization data for this DUR reporting period for all covered outpatient drugs paid. Exclude Third Party Liability.

(COMPLETE TABLE 2)

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

Table 2: Generic Drug Utilization

	Single Source (S) Drugs	Non-Innovator (N) Drugs	Innovator Multi-Source (I) Drugs
Total Number of Claims
Total Reimbursement Amount Less Co-Pay

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. This file will be made available from CMS to facilitate consistent reporting across States with this data request.