Improving Drug Utilization Review Controls in Part D
Medicare Part D sponsors must manage drug overutilization within their prescription drug plans as described in the Final CY 2013 Call Letter. The Improving Drug Utilization Review Controls in Part D website contains information to help Part D sponsors create or change their programs to address the unsafe use of opioid pain medications. This website also contains CMS communications to Part D sponsors regarding:
- Drug utilization management (DUM) guidance regarding the control of opioid and acetaminophen overutilization.
- The Overutilization Monitoring System (OMS), which helps CMS ensure that sponsors have established reasonable and appropriate drug utilization management programs to assist in preventing overutilization of certain prescribed medications.
- Sponsor Overutilization Beneficiary-level POS edit notifications reported to CMS through the PartD_OM@cms.hhs.gov mailbox and the Medicare Advantage Prescription System (MARx) Point-of-Sale (POS) Edit database, which collects beneficiary-level opioid POS edit information from sponsors for overutilizers identified in their plans and notifies a sponsor if a newly enrolled beneficiary had an active opioid POS edit while enrolled in the immediately preceding Part D contract.
Under Construction: 2019 Guidance on Drug Management Programs and Other Updates Coming Soon
Click the selection that best matches your information needs. Please check back, as we will continue to update these resources regularly.
- Medicare Part D Spring Conference 2018 CARA_Opioid Presentation [PDF, 332KB]
- Revised OMS Criteria Modification Analysis [PDF, 274KB]
- Medicare-PartD-Overutilization-Control-HPMS-memos [ZIP, 2MB]
- Medicare Part D Sponsor Overutilization Contact List (v April 2018) [ZIP, 122KB]
- CMS Final Call Letter 2013-2019 PartD DUR Controls Excerpts [ZIP, 2MB]
- Concurrent Use of Opioids and Benzodiazepines in a Medicare Part D Population, CY 2015 [PDF, 220KB]
- AHIP_Overutilization_Strategies_CMS_ 10192015 [PDF, 655KB]
- Model Letters (09/07/12) [ZIP, 143KB]
- GAO-11-699, MEDICARE PART D - Instances of Questionable Access to Prescription Drugs [PDF, 1MB]
- Opioid Morphine EQ Conversion Factors (vFeb 2018) [PDF, 83KB]
- Analysis of Conditions Associated with High Opioid Use (12/20/12) [PDF, 302KB]
- CDC: Analyzing Prescription data and Morphine Milligram Equivalents - Opens in a new window
- CDC Guideline for Prescribing Opioids for Chronic Pain - Opens in a new window
- Fact Sheet Overutilization Monitoring System (11/03/2015) - Opens in a new window
- 2013 Announcement [PDF, 1MB]
- Chapter 6 - Part D Drugs and Formulary Requirements (v02.19.10) [PDF, 643KB]
- Chapter 9 - Compliance Program Guidelines [PDF, 313KB]
- MAPD Plan Communications User Guide (PCUG)
- Page last Modified: 05/21/2018 9:51 AM
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