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Pharmacy Programs

As part of the initiative to combat the opioid epidemic, Buckeye Health Plan has adopted a Drug Management Program (DMP) for beneficiaries at-risk for misuse or abuse of frequently abused medications.

Background:

Section 704 of the Comprehensive Addiction and Recovery Act (CARA) of 2016 included provisions permitting Part D sponsors to establish Drug Management Programs (DMPs) for beneficiaries at-risk for misuse or abuse of frequently abused drugs (FADs).

CMS published a final rule (CMS-4182-F) on April 16, 2018 (“final rule”) that established the framework under which Part D plan sponsors may establish a DMP. This rule codified the many aspects of the retrospective Part D Opioid Drug Utilization Review (DUR) Policy and Overutilization Monitoring System (OMS), with adjustments as needed to comply with CARA, by integrating them into the DMP provisions at 42 CFR § 423.153(f).

Starting in January 2019, sponsors that adopted a DMP must engage in the case management of each Potential At-Risk Beneficiary (PARB) reported through OMS and provide information related to their review within 30 days. In addition, sponsors must also report through OMS any sponsor-identified PARBs, and any newly enrolled PARBs or At-Risk Beneficiaries (ARBs) for which a sponsor received a transaction reply code (TRC) of ‘376’ (New Enrollee CARA Status Notification) from the daily transaction reply report (DTRR).

See additional DMP guidance on the CMS Part D Overutilization website.

CMS policies also include drug management programs to encourage care coordination and safe use of opioids as required by the Comprehensive Addiction and Recovery Act of 2016. Starting in 2019, for patients who could potentially abuse or misuse prescription drugs - including opioids and benzodiazepines - a Medicare drug plan will contact prescribers through case management to review patients’ total utilization pattern of frequently abused drugs and discuss the following :

1. Use of opioids with an average daily morphine milligram equivalent (MME) equal to or exceeding 90 mg for any duration during the most recent 6 months and either: 3 or more opioid prescribers and 3 or more opioid dispensing pharmacies OR 5 or more opioid       prescribers, regardless of the number of opioid dispensing pharmacies. These cases are     identified through OMS or by sponsors.

2.  Use of opioids (regardless of average daily MME) during the most recent 6 months with 7 or more opioid prescribers OR 7 or more opioid dispensing pharmacies. These cases are identified by sponsors.