Improving Drug Utilization Review Controls

By Jason Hoyme
Tue, Nov, 21, 2017

CMS made two big changes for the 2018 data validation audit (based on 2017 data): first, CMS suspended the Sponsor Oversight of Agents section and second, CMS added the Improving Drug Utilization Review (I-DUR) Controls section. This blog post is about the addition of the I-DUR reporting section, focusing on the guidance posted by CMS.

In 2013, CMS implemented medication safety guidelines notifying health plans that they were expected to target potential overutilization of opioids. The guidance included the expectation of point-of-sale controls and reviews of member’s utilization history. CMS also developed the morphine equivalent dosage (MED) information to help identify high risk members. CMS has continually monitored this program to identify the overutilization of opioids while maintaining access to needed pain medications.

As part of this program for 2017, plans were required to implement a soft and/or hard edit at point-of-sale to help identify potential opioid overutilization. CMS recommended that a soft opioid edit threshold be set at levels no lower than 90 mg MED, and a hard opioid edit threshold be set no lower than 200 mg MED. The soft edit rejections can be overridden by the pharmacist while the hard edit rejections need an approved coverage determination to be filled.

Plans must also apply criteria to manage false positives for exceptions such as hospice care, certain cancer diagnosis, reasonable overlapping dates for refills, and fills previously determined as medically necessary through the coverage determination and appeals process.

For 2018 data validation, plans must report information about the edits in place including the MED threshold used, the number of provider criterion used, as well as the pharmacy criterion used. The count of rejections also needs to be reported including the number of unique beneficiaries impacted and the number of rejections overridden by the pharmacist or through a coverage determination or appeal. The data will need to be uploaded into the Health Plan Management System by February 26th, 2018 at the plan level.