23-1491m Stay in Compliance With Drug Utilization Review Requirements That Target Opioids

Date: 12/26/23

Changes can reduce fraud, misuse and abuse of prescription drugs

As a provider contracted with California Health & Wellness Plan (CHWP), you are receiving this information to keep you informed of CHWP’s (the Plan’s) responsibilities for a drug utilization review program. Entities delegated to fill prescriptions for outpatient drugs (“applicable entities”) would also be responsible for the requirements.

On September 25, 2023, the California Department of Health Care Services (DHCS) released All Plan Letter (APL) 23-026, which supersedes APL 19-012.

The Plan and applicable entities must comply with APL 23-026 and operate a drug utilization review (DUR) program¹ that complies with the Medicaid-related DUR provisions contained in section 1004 of the SUPPORT Act.

The health plan and applicable entities must:

1. Operate a DUR program.
2. Submit the following to the DHCS:

• Updated policies and procedures (P&Ps) that address each of the requirements detailed below.
• Annual DUR Report.

If the requirements contained in APL 23-026, including any updates or revisions to APL 23-026, necessitate a change in a managed care plan’s (MCP’s) contractually required P&Ps, the MCP must submit its updated P&Ps to its Managed Care Operations Division (MCOD) Contract Manager within 90 days of the release of APL 23-026. If an MCP determines that no changes to its P&Ps are necessary, the MCP must submit an email confirmation to its MCOD Contract Manager within 90 days of the release of APL 23-026, stating that the MCP’s P&Ps have been reviewed and no changes are necessary. The email confirmation must include the title of APL 23-026 as well as the applicable APL release date in the subject line.

Be aware of what’s required in the DUR program

Requirements include the following key elements.

Safety edits, including early, duplicate and quantity limits

Describe the opioid-related prospective safety edits, as well as the automated process for retrospective claims review that the Plan or the applicable entity has in place to address duplicate fill, early fill and quantity limits. The Plan and applicable entities must not allow refills earlier than 75% of the time when the previous fill should be exhausted; duplication of the same service on the same date of fill; and the provision of acute medications in excess of a 30-day supply, or for chronic medications, a 90-day supply without prior authorization approval.

Maximum daily morphine milligram equivalents (MME) safety edits

• Describe the prospective safety edits for the maximum MME/daily that can be prescribed to an MCP member enrolled for treatment of chronic pain, not to exceed 500 MME/daily without prior authorization. This safety edit must include an MME/daily threshold amount to assist in identifying MCP members at potentially high clinical risk who may benefit from closer monitoring and care coordination.
• Describe the automated process for claims review (retrospective review) that indicates when an MCP member is prescribed the morphine equivalent for such treatment in excess of the maximum MME/daily dose limitation.

Concurrent utilization alerts

Describe the automated process for claims review (retrospective) that monitors when an MCP member is concurrently prescribed opioids and benzodiazepines or opioids and antipsychotics. (This does not preclude the establishment of a prospective safety-edit system to provide additional information to patients and providers at the point-of-sale about concurrent utilization.) MCPs and applicable entities that are not capitated for antipsychotic drugs are provided claims data, including for antipsychotic medications. The Plan and applicable entities are expected to perform, retrospectively, regular care management activities, including a review of concurrent use of opioid and antipsychotic medications, and take action accordingly on issues of concern to them.

What’s excluded from the program

The above described safety edits and claims review requirements do not apply to MCP members who are receiving hospice or palliative care; receiving treatment for cancer; residents of a long-term care facility, a facility described in section 1905(d) of the Act, or of another facility for which frequently abused drugs are dispensed for residents through a contact with a single pharmacy; MCP members who are receiving opioid agonist medications for treatment of substance use disorder; or other individuals the state elects to treat as exempted from such requirements.

Monitor antipsychotic medications used for children

MCPs (and applicable entities) are required to have a process to monitor and manage appropriate use of all psychiatric drugs to include antipsychotics, mood stabilizers and anti-depressant medications for all children under age 18 and all foster children. Based on the DUR program monitoring findings, the DUR program must have a process to address and improve concerning findings.

Identify fraud, waste and abuse (FWA)

Describe the process for identifying and addressing fraud and abuse of controlled substances by MCP members, health care providers who are prescribing drugs to MCP members, and pharmacies dispensing drugs to MCP members. Also describe the actions that will be taken based on issues identified through program-monitoring findings.

How to report FWA

If you obtain information that reasonably leads you to believe there has or may have been a violation of law or of the Plan’s Compliance program, you must promptly report and disclose your concerns to the Plan’s Compliance Department. You also must cooperate with the Compliance Department in any audit or investigation implemented by the Plan due to your report. The Plan prohibits any form of retaliatory conduct or action against any employee or person who reports any compliance violation or concern.

Compliance Department hotline

Use the following contact information to report concerns to the Plan’s Compliance Department. A report may be made anonymously. All reports to the Compliance Department are treated as confidential to the greatest extent possible.

FWA hotline: 866-685-8664

E-mail

Background

Federal law² requires each state to develop a DUR program that is targeted, in part, at reducing clinical abuse and misuse of prescription drugs covered under the state’s Medicaid program. The SUPPORT Act added measures to combat the opioid crisis in part by reducing opioid abuse and misuse by advancing treatment and recovery initiatives, improving prevention, protecting communities and bolstering efforts to fight deadly illicit synthetic drugs. There were several Medicaid-related DUR provisions contained within section 1004 of the SUPPORT Act with respect to fee-for-service and managed care organization pharmacy programs. These provisions established drug review and utilization standards to supplement existing requirements under federal law, in an effort to reduce opioid-related fraud, abuse and misuse. Implementation and review of these strategies was required effective October 1, 2019.

The Centers for Medicare & Medicaid Services issued an Informational Bulletin on August 5, 2019³, providing states with detailed guidance on implementation of these specific new requirements. In addition, DHCS APL 19-012, Federal Drug Utilization Review Requirements Designed to Reduce Opioid-Related Fraud, Misuse and Abuse, describes MCPs’ responsibilities related to the implementation of the federal law. You can view APL 19-012 and APL 23-026.

Additional information

Relevant sections of the provider operations manual will be revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the provider website.

Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.

¹   The DUR program must comply with Medicaid-related DUR provisions contained in section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (H.R. 6, the SUPPORT Act, P.L. 115-271).

²   Section 1927(g) of the Social Security Act (the Act). Section 1927(g) of the Social Security Act (the Act) is available at: https://www.ssa.gov/OP_Home/ssact/title19/1927.htm.

³   The August 5, 2019, Informational Bulletin can be accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/cib080519-1004.pdf.

 

This information applies to Physicians, Independent Practice Associations (IPAs) and Ancillary Providers.