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.
Click the selection that best matches your information needs. Please check back, as we will continue to update these resources regularly.
- Revised OMS Criteria Modification Analysis [PDF, 274KB]
- Medicare PartD Overutilization Control HPMS memos [ZIP, 2MB]
- Medicare Part D Overutilization Contract List (v Sept 2017) [ZIP, 102KB]
- CMS Final Call Letter 2013-2017 PartD DUR Control Excerpts [ZIP, 1MB]
- 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-Aug-2017 [PDF, 78KB]
- 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: 09/19/2017 5:29 PM
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