New standards for Medicaid DUR programs to combat opioid misuse and abuse

Aug. 9, 2019

The Centers for Medicare & Medicaid Services (CMS) announced the release of new guidance to states to promote proper use of prescription opioids by updating standard requirements for the Medicaid Drug Utilization Review (DUR) program. The Medicaid DUR program is a two-phase process that screens drug claims to help identify clinical misuse or abuse and examines claims data to identify patterns of abuse.

The guidance will help states implement drug use review procedures newly required under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act), so state Medicaid programs can better monitor opioid prescribing and dispensing patterns, including new requirements for states to implement electronic notifications, also known as safety edits.

These notifications can alert healthcare professionals, such as pharmacists, of potential concerns with a medication prescribed for the patient that has to be resolved before it can be dispensed and safely taken by the patient.

Implementation of new Medicaid DUR standards carries out another part of the SUPPORT for Patients and Communities Act that will boost oversight of prescribing and dispensing opioids in state Medicaid programs. These reviews target:

· Requirements for refilling opioid prescriptions;

· Prescription monitoring for opioids and other drugs when prescribed at the same time, such as benzodiazepines;

· Antipsychotic prescription monitoring for children; and

· Fraud and abuse detection.

While many states already have safety edits and other procedures in place to monitor the use of opioids, today’s guidance assists states in implementing the SUPPORT for Patients and Communities Act requirement that state Medicaid programs apply opioid-specific safety edits. All states will be required to send alerts to pharmacists to identify Medicaid beneficiaries who may be refilling an opioid prescription too soon and may be in need of better pain management assistance.  

Section 1004 of the SUPPORT for Patients and Communities Act also requires all states to implement these requirements by October 1, 2019, and to submit an amendment to their State plan no later than December 31, 2019 in order to describe how the state addresses these provisions in the State plan.  States are also expected to give appropriate tribal notification, as required, if applicable. These new requirements apply to both patients enrolled in Medicaid fee-for-service (FFS) and certain Managed Care programs. States are required to report on these activities on an annual basis to CMS. 

This Medicaid DUR standards guidance coincides with bulletins CMS recently issued titled Caring Recovery for Infants and Babies (CRIB) and Help for Moms and Babies (HMBB) that provide further guidance for states how to implement additional treatment options for pregnant women, mothers, and infants affected by opioid misuse and abuse.