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.
- Fact Sheet Overutilization Monitoring System (11032015) [PDF, 144KB]
- AHIP_Overutilization_Strategies_CMS_ 10192015 [PDF, 655KB]
- HPMS memo: Updates—Medicare Part D Patient Safety, OMS and MARX POS Edit UI (04-08-2015) [PDF, 205KB]
- HPMS memo Beneficiary-Level Point-of-Sale Claim Edits and Other Overutilization Issues (8-25-2014) [PDF, 99KB]
- HPMS memo: Medicare Part D Overutilization Monitoring System (01/17/14) [PDF, 212KB]
- HPMS Memo: Medicare Part D Overutilization Monitoring System - Updates (10/25/13) [PDF, 81KB]
- HPMS memo: Medicare Part D Overutilization Monitoring System (07/05/13) [PDF, 82KB]
- HPMS memo: Reissued - Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D(09/07/2012) [PDF, 925KB]
- Model Letters (09/07/12) [ZIP, 143KB]
- Excerpt from Final 2013 Call Letter: Improving Drug Utilization Review Controls in Part D (04/02/2012) [PDF, 98KB]
- HPMS memo, Improving Drug Utilization Review Controls in Part D (09/28/11) [PDF, 98KB]
- GAO-11-699, MEDICARE PART D - Instances of Questionable Access to Prescription Drugs [PDF, 1MB]
- Opioid-Morphine-EQ-Conversion-Factors (March 2015) [PDF, 93KB]
- Part D Sponsor Overutilization Contact List (v January 2016) [ZIP, 104KB]
- Analysis of Conditions Associated with High Opioid Use (12/20/12) [PDF, 302KB]
- 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]
- Medicare Advantage and Prescription Drug Plans Communications User Guide
- Page last Modified: 01/07/2016 10:59 AM
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