Georgia
Medicaid Managed Care Organization (MCO)
FFY 2022 Drug Utilization
Review
(DUR)
Annual Report
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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Table of Contents
Section I - Demographic Information ..........................................................................................................................1
1. On average, how many Medicaid beneficiaries are enrolled monthly in your MCO for this Federal Fiscal Year? .... 1
Section II - Prospective DUR (ProDUR) ........................................................................................................................2
1. Indicate the type of your pharmacy point of service (POS) vendor and identify it by name. .................................... 2
2. Identify ProDUR table driven criteria source. ............................................................................................................. 3
3. When the pharmacist receives ProDUR alert message that requires a pharmacist’s review, does your system
allow the pharmacist to override the alert using the “National Council for Prescription Drug Program (NCPDP) drug
use evaluation codes”? ................................................................................................................................................... 4
4. Does your MCO receive periodic reports providing individual pharmacy providers DUR alert override activity in
summary and/or in detail? ............................................................................................................................................. 5
5. Early Refill ................................................................................................................................................................... 8
6. When the pharmacist receives an early refill DUR alert message that requires the pharmacist’s review does your
policy allow the pharmacist to override for situations such as: ................................................................................... 12
7. Does your system have an accumulation edit to prevent patients from continuously filling prescriptions early? . 13
8. Does the MCO have any policy prohibiting the auto-refill process that occurs at the POS? ................................... 15
9. Does your system have a diagnosis edit that can be utilized when processing a prescription? .............................. 16
10. For drugs not on your MCO’s Preferred Drug List (PDL), does your MCO have a documented process in place so
that the Medicaid beneficiary or the Medicaid beneficiary’s prescriber may access any covered outpatient drug
when medically necessary? .......................................................................................................................................... 17
11. Top Drug Claims Data Reviewed by the DUR Board: .............................................................................................. 21
Section III - Retrospective DUR (RetroDUR) ............................................................................................................... 22
1. Please indicate how your MCO operates and oversees RetroDUR reviews. ............................................................ 22
2. Identify the vendor, by name and type, that performed your RetroDUR activities during the time period covered
by this report. ............................................................................................................................................................... 23
3. Who reviews and approves your MCO RetroDUR criteria? ...................................................................................... 26
4. How often does your MCO perform retrospective practitioner-based education? ................................................. 27
5. Summary 1 - RetroDUR Educational Outreach ......................................................................................................... 30
Section IV - DUR Board Activity ................................................................................................................................ 36
1. Does your MCO utilize the same DUR Board as the State FFS Medicaid program or does your MCO have its own
DUR Board? ................................................................................................................................................................... 36
2. Does your MCO have a Medication Therapy Management (MTM) Program? ......................................................... 37
3. Summary 2 - DUR Board Activities ............................................................................................................................ 37
Section V - Physician Administered Drugs (PAD) ........................................................................................................ 42
1. ProDUR? .................................................................................................................................................................... 42
2. RetroDUR? ................................................................................................................................................................ 44
Section VI - Generic Policy and Utilization Data ......................................................................................................... 46
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1. Summary 3 - Generic Drug Substitution Policies ...................................................................................................... 46
2. In addition to the requirement that the prescriber write in his own handwriting “Brand Medically Necessary” for
a brand name drug to be dispensed in lieu of the generic equivalent, does your MCO have a more restrictive
requirement? ................................................................................................................................................................ 48
3. Indicate the generic utilization percentage for all CODs paid during this reporting period. ................................... 52
4. How many innovator drugs are the preferred product instead of their multi-source counterpart based on net
pricing? .......................................................................................................................................................................... 53
5. Indicate the percentage dollars paid for generic CODs in relation to all COD claims paid during this reporting
period. ........................................................................................................................................................................... 54
6. Does your MCO have any policies related to Biosimilars? ....................................................................................... 54
7. Does your Medicaid program provide coverage of over-the-counter medications when prescribed by an
authorized prescriber? .................................................................................................................................................. 55
Section VII - Fraud, Waste and Abuse Detection (FWA) ............................................................................................. 56
A. Lock-in or Patient Review and Restriction Programs .......................................................................................... 56
1. Does your MCO have a documented process in place that identifies potential FWA of controlled drugs by
beneficiaries? ................................................................................................................................................................ 56
2. Does your MCO have a lock-in program for beneficiaries with potential FWA of controlled substances? ............. 58
3. Does your MCO have a documented process in place that identifies potential FWA of controlled drugs by
prescribers?................................................................................................................................................................... 66
4. Does your MCO have a documented process in place that identifies potential FWA of controlled drugs by
pharmacy providers? .................................................................................................................................................... 69
5. Does your MCO have a documented process in place that identifies and/or prevents potential fraud or abuse of
non-controlled drugs by beneficiaries, prescribers, and pharmacy providers? ........................................................... 71
B. Prescription Drug Monitoring Program (PDMP) ................................................................................................. 73
1. Does your MCO have the ability to query the State’s PDMP database? .................................................................. 73
2. Have you communicated to prescribers who are covered providers that as of October 1, 2021, they are required
to check the PDMP before prescribing controlled substances to beneficiaries who are covered individuals? ........... 78
3. In the State’s PDMP system, which of the following beneficiary information is available to prescribers as close to
real-time as possible? ................................................................................................................................................... 83
4. Have any changes to your State’s PDMP during this reporting period improved or detracted from the Medicaid
program’s ability to access PDMP data? ....................................................................................................................... 85
5. In this reporting period, have there been any data or privacy breaches of the PDMP or PDMP data?................... 86
C. Opioids............................................................................................................................................................. 87
1. For your program, is this category of medications carved out and handled by the State? ..................................... 87
2. Does your MCO currently have a POS edit in place to limit the days’ supply dispensed of an initial opioid
prescription for opioid naïve patients?......................................................................................................................... 88
3. Does your MCO have POS edits in place to limit the quantity dispensed of opioids? ............................................. 90
4. Does your MCO have measures other than restricted quantities and days’ supply in place to either monitor or
manage the prescribing of opioids? ............................................................................................................................. 93
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5. Does your MCO have POS edits to monitor duplicate therapy of opioid prescriptions? This excludes regimens that
include a single extended release product and a breakthrough short acting agent. ................................................... 96
6. Does your MCO have POS edits to monitor early refills of opioid prescriptions dispensed?................................... 97
7. Does your MCO have comprehensive automated retrospective claim reviews to monitor opioid prescriptions
exceeding program limitations? ................................................................................................................................... 98
8. Does your MCO currently have POS edits in place or automated retrospective claim reviews to monitor opioids
and benzodiazepines being used concurrently? ........................................................................................................... 99
9. Does your MCO currently have POS edits in place or automated retrospective claim reviews to monitor opioids
and sedatives being used concurrently? .................................................................................................................... 100
10. Does your MCO currently have POS edits in place or an automated retrospective claims review process to
monitor opioids and antipsychotics being used concurrently? .................................................................................. 101
11. Does your MCO have POS safety edits or perform automated respective claims reviews and/or provider
education regarding beneficiaries with a diagnosis or history of opioid use disorder (OUD) or opioid poisoning
diagnosis?.................................................................................................................................................................... 102
12. Does your MCO program develop and provide prescribers with pain management or opioid prescribing
guidelines? .................................................................................................................................................................. 105
13. Does your MCO have a drug utilization management strategy that supports abuse deterrent opioid use to
prevent opioid misuse and abuse? ............................................................................................................................. 107
14. Were there COVID-19 ramifications on edits and reviews on controlled substances during the public health
emergency? ................................................................................................................................................................. 108
D. Morphine Milligram Equivalent (MME) Daily Dose .......................................................................................... 109
1. Have you set recommended maximum MME daily dose measures? ..................................................................... 109
2. Does your MCO have an edit in your POS system that alerts the pharmacy provider that the MME daily dose
prescribed has been exceeded? ................................................................................................................................. 111
3. Does your MCO have an automated retrospective claims review to monitor the MME total daily dose of opioid
prescriptions dispensed? ............................................................................................................................................ 113
4. Does your MCO provide information to your prescribers on how to calculate the MME daily dosage or does your
MCO provide a calculator developed elsewhere? ...................................................................................................... 114
E. Opioid Use Disorder (OUD) Treatment ............................................................................................................ 117
1. Does your MCO have utilization controls to either monitor or manage the prescribing of Medication Assisted
Treatment (MAT) drugs for OUD? .............................................................................................................................. 117
2. Does your MCO set total mg per day limits on the use of buprenorphine and buprenorphine/naloxone
combination drugs? .................................................................................................................................................... 118
3. What are your limitations on the allowable length of this treatment? .................................................................. 120
4. Does your MCO require that the maximum mg per day allowable be reduced after a set period of time? ......... 121
5. Does your MCO have at least one buprenorphine/naloxone combination product available without PA? .......... 122
6. Does your MCO currently have edits in place to monitor opioids being used concurrently with any buprenorphine
drug or any form of MAT? .......................................................................................................................................... 123
7. Is there at least one formulation of naltrexone for OUD available without PA? ................................................... 125
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8. Does your MCO have at least one naloxone opioid overdose product available without PA? .............................. 126
9. Does your MCO monitor and manage appropriate use of naloxone to persons at risk of overdose? ................... 127
10. Does your MCO allow pharmacists to dispense naloxone prescribed independently or by collaborative practice
agreements, or standing orders, or other predetermined protocols? ....................................................................... 128
F. Outpatient Treatment Programs (OTP) ............................................................................................................ 129
1. Does your MCO cover OTPs that provide behavioral health (BH) and MAT through OTPs? .................................. 129
2. Does your MCO cover buprenorphine or buprenorphine/naloxone for diagnoses of OUD as part of a
comprehensive MAT treatment plan through OTPs? ................................................................................................. 131
3. Does your MCO cover naltrexone for diagnoses of OUD as part of a comprehensive MAT treatment plan? ....... 132
4. Does your MCO cover Methadone for substance use disorder? ............................................................................ 133
G. Psychotropic Medication For Children ............................................................................................................. 134
Antipsychotics .................................................................................................................................................... 134
1. Does your MCO currently have restrictions in place to limit the quantity of antipsychotic drugs? ...................... 134
2. Does your MCO have a documented program in place to either manage or monitor the appropriate use of
antipsychotic drugs in children? ................................................................................................................................. 135
Stimulants .......................................................................................................................................................... 139
3. Does your MCO currently have restrictions in place to limit the quantity of stimulant drugs? ............................. 139
4. Do you have a documented program in place to either manage or monitor the appropriate use of stimulant drugs
in children? ................................................................................................................................................................. 140
Antidepressants ................................................................................................................................................. 144
5. Does your MCO have a documented program in place to either manage or monitor the appropriate use of
antidepressant drugs in children? .............................................................................................................................. 144
Mood Stabilizers ................................................................................................................................................ 148
6. Does your MCO have a documented program in place to either manage or monitor the appropriate use of mood
stabilizing drugs in children? ....................................................................................................................................... 148
Antianxiety/Sedatives ........................................................................................................................................ 151
7. Does your MCO have a documented program in place to either manage or monitor the appropriate use of
antianxiety/sedative drugs in children?...................................................................................................................... 151
Section VIII - Innovative Practices ........................................................................................................................... 155
1. Does your MCO participate in any demonstrations or have any waivers to allow importation of certain drugs from
Canada or other countries that are versions of FDA-approved drugs for dispensing to Medicaid Beneficiaries? .... 155
2. Summary 4 - Innovative Practices ........................................................................................................................... 155
Section IX - Executive Summary .............................................................................................................................. 158
1. Summary 5 - Executive Summary ........................................................................................................................... 158
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List of Figures
Figure 1 - Number of Beneficiaries Enrolled in Each MCO ..................................................................................................... 1
Figure 2 - Pharmacy POS Type of Vendor ............................................................................................................................... 2
Figure 3 - Prospective DUR Criteria Source ............................................................................................................................. 3
Figure 4 - ProDUR Alert Message for Pharmacist Override using “NCPDP Drug Use Evaluation Codes” ............................... 4
Figure 5 - Receives Periodic Reports Providing Individual Pharmacy Providers DUR Alert Override Activity ........................ 5
Figure 6 - Frequency of Reports Providing Individual Pharmacy Provider DUR Alert Override Activity ................................ 6
Figure 7 - Follow up with Providers who Routinely Override with Interventions .................................................................. 7
Figure 8 - Non-Controlled Drugs Early Refill Percent Edit Threshold ...................................................................................... 8
Figure 9 - Schedule II Controlled Drugs Early Refill Percent Edit Threshold ........................................................................... 8
Figure 10 - Schedule III through V Controlled Drugs Early Refill Percent Edit Threshold ....................................................... 9
Figure 11 - Non-Controlled Drugs Early Refill Requirement for Prior Authorization ............................................................ 10
Figure 12 - Non-Controlled Drugs Early Refill Authorization Sources ................................................................................... 10
Figure 13 - Controlled Drugs, Early Refill Requirement for MCO Prior Authorization .......................................................... 11
Figure 14 - Controlled Drugs Early Refill Authorization Source ............................................................................................ 11
Figure 15 - Policy Allows Pharmacist Overrides for an Early Refill ....................................................................................... 12
Figure 16 - System Accumulation Edit for Prevention of Early Prescription Filling .............................................................. 13
Figure 17 - Plans to Implement a System Accumulation Edit ............................................................................................... 14
Figure 18 - MCO Policy Prohibiting Auto-Refill at the POS ................................................................................................... 15
Figure 19 - System Having a Diagnosis Edit That Can be Utilized When Processing Prescription ........................................ 16
Figure 20 - Documented Process for Beneficiaries or their Prescribers to Access Any Covered Outpatient Drug (COD)
when Medically Necessary .................................................................................................................................................... 17
Figure 21 - Documented Process in Place for Beneficiaries to Access Any Covered Outpatient Drug (COD) When Medically
Necessary .............................................................................................................................................................................. 18
Figure 22 - Program Provides for the Dispensing of at least a 72-hour Supply of a COD in Emergency Situations ............. 19
Figure 23 - Process for the Dispensing of at least a 72-Hour Supply of CODs in Emergency Situations .............................. 20
Figure 24 - Operation and Oversight of RetroDUR Reviews ................................................................................................. 22
Figure 25 - Type of Vendor that Performed RetroDUR Activities ......................................................................................... 23
Figure 26 - RetroDUR Vendor is the Developer/Supplier of Retrospective DUR Criteria ..................................................... 24
Fi
gure 27 - MCO Customizes RetroDUR Vendor Criteria ...................................................................................................... 25
Figure 28 - RetroDUR Criteria Approval/Review Sources ..................................................................................................... 26
Figure 29 - Frequency of Retrospective Practitioner-Based Education ................................................................................ 27
Figure 30 - Frequency of Retrospective Reviews that Involve Communication of Client-Specific Information to Healthcare
Practitioners .......................................................................................................................................................................... 28
Figure 31 - Preferred Mode of Communication When Performing RetroDUR Initiatives .................................................... 29
Figure 32 - MCO Utilizes the Same DUR Board as the State FFS Program or Has Own DUR Board ..................................... 36
Figure 33 - MCO has a Medication Therapy Management Program .................................................................................... 37
Figure 34 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for ProDUR . 42
Figure 35 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
ProDUR .................................................................................................................................................................................. 43
Figure 36 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for RetroDUR
.............................................................................................................................................................................................. 44
Figure 37 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
RetroDUR .............................................................................................................................................................................. 45
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Figure 38 - More Restrictive MCO Requirements than the Prescriber Writing in His Own Handwriting “Brand Medically
Necessary” for a Brand Name Drug ...................................................................................................................................... 48
Figure 39 - Additional Restrictive MCO Requirements for Dispensing a Brand Name Drug ................................................ 49
Figure 40 - Total Single Source (S) Drug Claims by MCO ...................................................................................................... 50
Figure 41 - Total Non-Innovator (N) Drug Claims by MCO ................................................................................................... 51
Figure 42 - Total Innovator Multi-Source (I) Drug Claims by MCO ....................................................................................... 51
Figure 43 - Generic Utilization Percentage ........................................................................................................................... 52
Figure 44 - Innovator Drugs That Are The Preferred Product Instead Of Their Multi-Source Counterpart Based On Net
Pricing .................................................................................................................................................................................... 53
Figure 45 - Percentage Dollars Paid for Generic CODs ......................................................................................................... 54
Figure 46 - Medicaid Program Providing Coverage of Over-the-Counter Medications When Prescribed by an Authorized
Prescriber .............................................................................................................................................................................. 55
Figure 47 - Documented Process in Place to Identify Potential FWA of Controlled Drugs by Beneficiaries ........................ 56
Figure 48 - Actions Process Initiates when Potential FWA of Controlled Drugs by Beneficiaries is Detected ..................... 57
Figure 49 - Lock-In Program .................................................................................................................................................. 58
Figure 50 - Lock-In Program Candidate Identification Criteria ............................................................................................. 59
Figure 51 - Prescriber Only Restriction Capability ................................................................................................................ 60
Figure 52 - Pharmacy Only Restriction Capability ................................................................................................................. 61
Figure 53 - Prescriber and Pharmacy Restriction Capability ................................................................................................. 62
Figure 54 - Lock-In Time Period ............................................................................................................................................ 63
Figure 55 - Percentage of Medicaid MCO Population in Lock-In Status Annually ................................................................ 64
Figure 56 - Estimate of Savings Attributed to the Lock-In Program for the Fiscal Year Under Review ................................ 65
Figure 57 - Documented Process to Identify Potential FWA of Controlled Drugs by Prescribers ........................................ 66
Figure 58 - Actions Process Initiates when Potential FWA of Controlled Drugs by Prescribers is Detected ........................ 67
Figure 59 - Documented Process to Identify Potential FWA of Controlled Drugs by Pharmacy Providers .......................... 69
Figure 60 - Actions when Potential FWA of Controlled Drugs by Pharmacy Providers is Detected ..................................... 70
Figure 61 - Documented Process to Identify Potential Fraud or Abuse of Non-Controlled Drugs by Beneficiaries,
Prescribers, and Pharmacy Providers ................................................................................................................................... 71
Figure 62 - MCO Has Ability to Query the State’s PDMP database ...................................................................................... 73
Figure 63 - Ways the MCO Has the Ability to Query the State’s PDMP Database ................................................................ 74
Figure 64 - Query Capability .................................................................................................................................................. 75
Figure 65 - MCO Access to Contiguous States’ PDMP Information ...................................................................................... 76
Figure 66 - MCO Has PDMP Data Integrated into POS Edits ................................................................................................. 77
Figure 67 - Communicated that Prescribers are Required to Access the PDMP Patient History Before Prescribing
Controlled Substances .......................................................................................................................................................... 78
Figure 68 - Ways MCO Has Communicated Requirement .................................................................................................... 79
Figure 69 - Protocols Involved in Checking the PDMP .......................................................................................................... 80
Figure 70 - Providers Having Protocols for Responses to Information from the PDMP that is Contradictory to the
Information the Practitioner Expects .................................................................................................................................... 81
Figure 71 - MCO Requires Prescriber to Document a Good Faith Effort if Unable to Conduct a PDMP Check ................... 82
Figure 72 - Beneficiary Information Available to Prescribers as Close to Real-Time as Possible ......................................... 83
Figure 73 - Barriers Hinder MCO from Fully Accessing the PDMP to Curb FWA .................................................................. 84
Figure 74 - Changes to State PDMP That Have Improved or Detracted from the Medicaid Program’s Ability to Access
PDMP Data ............................................................................................................................................................................ 85
Figure 75 - Data or Privacy Breaches of PDMP or PDMP Data During This Reporting Period .............................................. 86
Figure 76 - Opioid Category of Medications Carved Out and Handled by the State ............................................................ 87
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Figure 77 - POS Edit in Place to Limit the Days’ Supply Dispensed of an Initial Opioid Prescription for Opioid Naïve
Patients ................................................................................................................................................................................. 88
Figure 78 - Maximum Number of Days Allowed for an Initial Opioid Prescription for Opioid Naïve Patients ..................... 89
Figure 79 - POS Edits in Place to Limit the Quantity Dispensed of Opioids .......................................................................... 90
Figure 80 - POS Edits in Place to Limit the Quantity Dispensed of Short-Acting (SA) Opioids.............................................. 91
Figure 81 - POS Edits in Place to Limit the Quantity Dispensed of Long-Acting Opioids ...................................................... 92
Figure 82 - Have Measures Other Than Restricted Quantities and Days’ Supply in Place to Either Monitor or Manage the
Prescribing of Opioids ........................................................................................................................................................... 93
Figure 83 - Measures other than Restricted Quantities and Days’ Supply in Place to Either Monitor or Manage the
Prescribing of Opioids ........................................................................................................................................................... 94
Figure 84 - POS Edits to Monitor Duplicate Therapy of Opioid Prescriptions ...................................................................... 96
Figure 85 - POS Edits to Monitor Early Refills of Opioid Prescriptions Dispensed ................................................................ 97
Figure 86 - Automated Retrospective Claim Reviews to Monitor Opioid Prescriptions in Excess of Program Limitations . 98
Figure 87 - POS Edits or Automated Retrospective Claim Reviews to Monitor Opioids and Benzodiazepines Used
Concurrently ......................................................................................................................................................................... 99
Figure 88 - POS Edits or Automated Retrospective Claim Reviews to Monitor Opioids and Sedatives Being Used
Concurrently ....................................................................................................................................................................... 100
Figure 89 - POS Edits or Automated Retrospective Claim Reviews to Monitor Opioids and Antipsychotics Being Used
Concurrently ....................................................................................................................................................................... 101
Figure 90 - POS Safety Edits, Automated Retrospective Claims Reviews and/or Provider Education Regarding
Beneficiaries with a Diagnosis or History of OUD or Opioid Poisoning Diagnosis .............................................................. 102
Figure 91 - POS Safety Edits, Automated Retrospective Claims Reviews and/or Provider Education Regarding
Beneficiaries with a Diagnosis or History of OUD or Opioid Poisoning Diagnosis .............................................................. 103
Figure 92 - Frequency of Automated Retrospective Reviews and/or Provider Education Regarding Beneficiaries with a
Diagnosis or History of OUD or Opioid Poisoning Diagnosis............................................................................................... 104
Figure 93 - Provide Prescribers with Pain Management or Opioid Prescribing Guidelines ................................................ 105
Figure 94 - Pain Management / Opioid Prescribing Guidelines Provided........................................................................... 106
Figure 95 - Drug Utilization Management Strategy that Supports Abuse Deterrent Opioid Use ....................................... 107
Figure 96 - COVID-19 Ramifications on Edits and Reviews on Controlled Substances During the Public Health Emergency
............................................................................................................................................................................................ 108
Figure 97 - MCO Recommended MME Daily Dose Measures ............................................................................................ 109
Figure 98 - Maximum MME Daily Dose Limit in Milligrams ................................................................................................ 110
Figure 99 - Edit in POS System that Alerts the Pharmacy Provider that the MME Daily Dose has been Exceeded ........... 111
Figure 100 - Prior Authorization Required if MME Limit is Exceeded ................................................................................ 112
Figure 101 - MCO Has Automated Retrospective Claim Reviews to Monitor MME Total Daily Dose ................................ 113
Figure 102 - Provide Information to Prescribers to Calculate the MME Daily Dosage or Provide a Calculator Developed
Elsewhere ............................................................................................................................................................................ 114
Figure 103 - Developer of the MME Daily Dosage Calculator ............................................................................................. 115
Figure 104 - Information Dissemination Routes ................................................................................................................. 116
Figure 105 - MCO Has Utilization Controls to Monitor/Manage Prescribing of MAT Drugs for OUD ................................ 117
Figure 106 - MCO Sets Total Milligram per Day Limits on the Use of Buprenorphine and Buprenorphine/Naloxone
Combination Drugs ............................................................................................................................................................. 118
Figure 107 - Total Milligrams/Day Limit on the Use of Buprenorphine and Buprenorphine/Naloxone Combination Drugs
............................................................................................................................................................................................ 119
Figure 108 - Limitations on Allowable Length of Treatment of Buprenorphine/Naloxone Combination Drugs ................ 120
Figure 109 - Maximum Milligrams per Day Reduction After a Set Period of Time ............................................................. 121
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Figure 110 - Buprenorphine/Naloxone Combination Product Available Without Prior Authorization .............................. 122
Figure 111 - Edits in Place to Monitor Opioids Being Used Concurrently with Any Buprenorphine Drug or Any Form of
MAT ..................................................................................................................................................................................... 123
Figure 112 - POS Pharmacist Override Edit for Opioids Being Used Concurrently with Any Buprenorphine Drug or Any
Form of MAT ....................................................................................................................................................................... 124
Figure 113 - Formulation of Naltrexone for OUD Available Without PA ............................................................................ 125
Figure 114 - Naloxone Opioid Overdose Product Available Without PA ............................................................................ 126
Figure 115 - Monitor and Manage Appropriate Use of Naloxone to Persons at Risk of Overdose ................................... 127
Figure 116 - MCO Allows Pharmacists to Dispense Naloxone Prescribed Independently or by Collaborative Practice
Agreements, Standing Orders, Or Other Predetermined Protocols ................................................................................... 128
Figure 117 - MCO Covers OTPs That Provide BH and MAT Through OTPs ......................................................................... 129
Figure 118 - Referral Required for OUD Treatment Through OTPs .................................................................................... 130
Figure 119 - MCO Covers Buprenorphine or Buprenorphine/Naloxone for Diagnoses of OUD as Part of a MAT Treatment
Plan...................................................................................................................................................................................... 131
Figure 120 - MCO Covers Naltrexone for Diagnoses of OUD as Part of a MAT Treatment Plan ........................................ 132
Figure 121 - MCO Covers Methadone for Substance Use Disorder .................................................................................... 133
Figure 122 - Restrictions to Limit Quantity of Antipsychotics ............................................................................................ 134
Figure 123 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Antipsychotic Drugs in
Children ............................................................................................................................................................................... 135
Figure 124 - Categories of Children Either Managed or Monitored for Appropriate Use of Antipsychotic Drugs ............. 136
Figure 125 - Edits in Place to Monitor the Appropriate Use of Antipsychotic Drugs in Children ....................................... 137
Figure 126 - Restrictions in Place to Limit the Quantity of Stimulant Drugs ...................................................................... 139
Figure 127 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Stimulant Drugs in
Children ............................................................................................................................................................................... 140
Figure 128 - Categories of Children Either Managed or Monitored for Appropriate Use of Stimulant Drugs ................... 141
Figure 129 - Edits in Place to Monitor the Appropriate Use of Stimulant Drugs in Children ............................................. 142
Figure 130 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Antidepressant Drugs in
Children ............................................................................................................................................................................... 144
Figure 131 - Categories of Children Either Managed or Monitored for Appropriate Use of Antidepressant Drugs .......... 145
Figure 132 - Edits in Place to Monitor the Appropriate Use of Antidepressant Drugs in Children .................................... 146
Figure 133 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Mood Stabilizing Drugs
in Children ........................................................................................................................................................................... 148
Figure 134 - Categories of Children Either Managed or Monitored for Appropriate Use of Mood Stabilizing Drugs ........ 149
Figure 135 - Edits in Place to Monitor the Appropriate Use of Mood Stabilizing Drugs in Children .................................. 150
Fi
gure 136 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Antianxiety/Sedative
Drugs in Children ................................................................................................................................................................. 151
Figure 137 - Categories of Children Either Managed or Monitored for Appropriate Use of Antianxiety/Sedative Drugs . 152
Figure 138 - Edits in Place to Monitor the Appropriate Use of Antianxiety/Sedative Drugs in Children ........................... 153
Figure 139 - Demonstrations or Waivers to Allow Importation of Certain Drugs from Canada or Other Countries that are
Versions of FDA-Approved Drugs for Dispensing to Medicaid Beneficiaries ...................................................................... 155
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List of Tables
Table 1 - Number of Beneficiaries Enrolled in Each MCO ....................................................................................................... 1
Table 2 - Pharmacy POS Type of Vendor ................................................................................................................................ 2
Table 3 - Pharmacy POS Vendor Name ................................................................................................................................... 2
Table 4 - Prospective DUR Criteria Source .............................................................................................................................. 3
Table 5 - “Other” Explanations for Prospective DUR Criteria Source ..................................................................................... 3
Table 6 - ProDUR Alert Message for Pharmacist Override using “NCPDP Drug Use Evaluation Codes” ................................ 4
Table 7 - ProDUR Alert Types for Pharmacist Override .......................................................................................................... 4
Table 8 - Explanation for “Other” ProDUR Alert Types for Pharmacist Override ................................................................... 5
Table 9 - Receives Periodic Reports Providing Individual Pharmacy Provider DUR Alert Override Activity ........................... 5
Table 10 - Frequency of Reports Providing Individual Pharmacy Provider DUR Alerts Override Activity .............................. 6
Table 11 - Follow up with Providers who Routinely Override with Interventions .................................................................. 7
Table 12 - “No” Explanations for Receiving Periodic Reports Providing Individual Pharmacy Provider DUR Alert Override
Activity .................................................................................................................................................................................... 7
Table 13 - Early Refill Percent Threshold for Non-controlled and Controlled Drugs .............................................................. 9
Table 14 - Non-Controlled Drugs Early Refill Requirement and Authorization Source for Prior Authorization ................... 11
Table 15 - For Controlled Drugs, Early Refill Requirement and Authorization Source for Prior Authorization .................... 12
Table 16 - Policy Allows Pharmacist Overrides for an Early Refill ......................................................................................... 12
Table 17 - “Other” Explanations for Allowing Pharmacist Overrides for an Early Refill ....................................................... 12
Table 18 - System Accumulation Edit for Prevention of Early Prescription Filling ............................................................... 13
Table 19 - Explanations for System Accumulation Edit for Prevention of Early Prescription Filling .................................... 13
Table 20 - Plans to Implement a System Accumulation Edit ................................................................................................ 14
Table 21 - MCO Policy Prohibiting Auto-Refill at the POS .................................................................................................... 15
Table 22 - System Having a Diagnosis Edit That Can be Utilized When Processing Prescription ......................................... 16
Table 23 - Explanations for System Having a Diagnosis Edit That Can be Utilized When Processing Prescription .............. 16
Table 24 - Documented Process for Beneficiaries or their Prescribers to Access Any Covered Outpatient Drug (COD) when
Medically Necessary.............................................................................................................................................................. 17
Table 25 - Documented Process in Place for Beneficiaries to Access Any Covered Outpatient Drug (COD) When Medically
Necessary .............................................................................................................................................................................. 18
Table 26 - Explanations for “Other” Processes in Place for Beneficiaries to Access Any Covered Outpatient Drug When
Medically Necessary.............................................................................................................................................................. 18
T
able 27 - How MCO Ensures PA Criteria is No More Restrictive than FFS Criteria and Review .......................................... 19
Table 28 - Program Provides for the Dispensing of at least a 72-hour Supply of a COD in Emergency Situations .............. 20
Table 29 - Process for the Dispensing of at least a 72-Hour Supply of CODs in Emergency Situations ................................ 20
Table 30 - Explanations of “Other Process” for the Dispensing of at least a 72-Hour Supply of CODs in Emergency
Situations .............................................................................................................................................................................. 20
Table 31 - Top Drug Claims Data Reviewed by the DUR Board* .......................................................................................... 21
Table 32 - Operation and Oversight of RetroDUR Reviews .................................................................................................. 22
Table 33 - “Other” Explanations for Operation and Oversight of RetroDUR Reviews ......................................................... 22
Table 34 - Type of Vendor that Performed RetroDUR Activities .......................................................................................... 23
Table 35 - Vendor Names ...................................................................................................................................................... 23
Table 36 - RetroDUR Vendor is the Developer/Supplier of Retrospective DUR Criteria ...................................................... 24
Table 37 - “Yes” Explanations for RetroDUR Vendor Developer/Supplier of Retrospective DUR Criteria ........................... 24
Table 38 - MCO Customizes RetroDUR Vendor Criteria ....................................................................................................... 25
Table 39 - RetroDUR Criteria Approval/Review Sources ...................................................................................................... 26
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Table 40 - “Other” Explanations RetroDUR Criteria Approval/Review Sources ................................................................... 26
Table 41 - Frequency of Retrospective Practitioner-Based Education ................................................................................. 27
Table 42 - “Other” Frequency of Retrospective Practitioner-Based Education .................................................................... 27
Table 43 - Frequency of Retrospective Reviews that Involve Communication of Client-Specific Information to Healthcare
Practitioners .......................................................................................................................................................................... 28
Table 44 - “Other” Explanations for Frequency of Retrospective Reviews that Involve Communication of Client-Specific
Information to Healthcare Practitioners ............................................................................................................................... 28
Table 45 - Preferred Mode of Communication When Performing RetroDUR Initiatives ..................................................... 29
Table 46 - “Other” Explanations for Preferred Mode of Communication When Performing RetroDUR Initiatives ............. 30
Table 47 - RetroDUR Educational Outreach .......................................................................................................................... 30
Table 48 - MCO Utilizes the Same DUR Board as the State FFS Program or Has Own DUR Board ...................................... 36
Table 49 - “Other” Explanations for MCO not Utilizing the Same DUR Board as the State FFS Program or its Own DUR
Board ..................................................................................................................................................................................... 36
Table 50 - MCO has a Medication Therapy Management Program ..................................................................................... 37
Table 51 - DUR Board Activities ............................................................................................................................................ 37
Table 52 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for ProDUR... 42
Table 53 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
ProDUR .................................................................................................................................................................................. 43
Table 54 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for RetroDUR 44
Table 55 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
RetroDUR .............................................................................................................................................................................. 45
Table 56 - Generic Drug Substitution Policies ....................................................................................................................... 46
Table 57 - More Restrictive MCO Requirements than the Prescriber Writing in His Own Handwriting “Brand Medically
Necessary” for a Brand Name Drug ...................................................................................................................................... 49
Table 58 - Additional Restrictive MCO Requirements for Dispensing a Brand Name Drug .................................................. 49
Table 59 - “Other” Explanations for Additional Restrictive MCO Requirements for Dispensing a Brand Name Drug ......... 49
Table 60 - Generic Drug Utilization Data: Single Source Innovator(S), Innovator Multiple-Source (I), Non-Innovator
Multiple-Source (N) ............................................................................................................................................................... 52
Table 61 - Generic Utilization Percentage ............................................................................................................................ 52
Table 62 - Innovator Drugs That Are The Preferred Product Instead Of Their Multi-Source Counterpart Based On Net
Pricing .................................................................................................................................................................................... 53
Table 63 - Percentage Dollars Paid for Generic CODs ........................................................................................................... 54
Table 64 - Explanations for MCO Policies Related to Biosimilars ......................................................................................... 54
Table 65 - Medicaid Program Providing Coverage of Over-the-Counter Medications When Prescribed by an Authorized
Prescriber .............................................................................................................................................................................. 55
Table 66 - Documented Process in Place to Identify Potential FWA of Controlled Drugs by Beneficiaries ......................... 56
Table 67 - Actions Process Initiates when Potential FWA of Controlled Drugs by Beneficiaries is Detected ...................... 57
Table 68 - Lock-In Program ................................................................................................................................................... 58
Table 69 - Lock-In Program Candidate Identification Criteria............................................................................................... 59
Table 70 - “Other” Explanations for Lock-In Program Candidate Identification Criteria ...................................................... 59
Table 71 - Prescriber Only Restriction Capability .................................................................................................................. 60
Table 72 - Pharmacy Only Restriction Capability .................................................................................................................. 61
Table 73 - Prescriber and Pharmacy Restriction Capability .................................................................................................. 62
Table 74 - Lock-In Time Period .............................................................................................................................................. 63
Table 75 - Percentage of Medicaid MCO Population in Lock-In Status Annually ................................................................. 64
Table 76 - Estimate of Savings Attributed to the Lock-In Program for the Fiscal Year Under Review ................................. 65
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Table 77 - Documented Process to Identify Potential FWA of Controlled Drugs by Prescribers ......................................... 66
Table 78 - Actions Process Initiates when Potential FWA of Controlled Drugs by Prescribers is Detected ......................... 67
Table 79 - “Other” Explanations for Action Initiated by Documented Process to Identify Potential FWA of Controlled
Drugs by Prescribers ............................................................................................................................................................. 67
Table 80 - Documented Process to Identify Potential FWA of Controlled Drugs by Pharmacy Providers ........................... 69
Table 81 - Actions when Potential FWA of Controlled Drugs by Pharmacy Providers is Detected ...................................... 70
Table 82 - “Other” Explanations when Potential FWA of Controlled Drugs by Pharmacy Providers is Detected ................ 70
Table 83 - Documented Process to Identify Potential Fraud or Abuse of Non-Controlled Drugs by Beneficiaries,
Prescribers, and Pharmacy Providers ................................................................................................................................... 71
Table 84 - Explanations of Program for FWA of Non-Controlled Substances by Beneficiaries, Prescribers, and Pharmacy
Providers ............................................................................................................................................................................... 72
Table 85 - MCO Has Ability to Query the State’s PDMP Database ....................................................................................... 73
Table 86 - Explanations for MCO Not Having the Ability to Query the State’s PDMP Database .......................................... 73
Table 87 - Ways the MCO Has the Ability to Query the State’s PDMP Database ................................................................. 74
Table 88 - Query Capability ................................................................................................................................................... 75
Table 89 - Explanation for How MCO Program Applies Information to Control FWA of Controlled Substances ................. 75
Table 90 - MCO Access to Contiguous States’ PDMP Information ....................................................................................... 76
Table 91 - MCO Has PDMP Data Integrated into POS Edits .................................................................................................. 77
Table 92 - Communicated that Prescribers are Required to Access the PDMP Patient History Before Prescribing
Controlled Substances .......................................................................................................................................................... 78
Table 93 - Ways MCO Has Communicated Requirement ..................................................................................................... 79
Table 94 - “Not Applicable” Explanations for Communicating to Prescribers they are Required to Access the PDMP
Patient History Before Prescribing Controlled Substances ................................................................................................... 79
Table 95 - “No” Explanations for Communicating to Prescribers they are Required to Access the PDMP Patient History
Before Prescribing Controlled Substances ............................................................................................................................ 79
Table 96 - Protocols Involved in Checking the PDMP ........................................................................................................... 80
Table 97 - Providers Having Protocols for Responses to Information from the PDMP that is Contradictory to the
Information the Practitioner Expects .................................................................................................................................... 81
Table 98 - MCO Requires Prescriber to Document a Good Faith Effort if Unable to Conduct a PDMP Check ..................... 82
Table 99 - Explanations for not Requiring Prescribers to Document a Good Faith Effort .................................................... 82
Table 100 - Beneficiary Information Available to Prescribers as Close to Real-Time as Possible ......................................... 83
Table 101 - Barriers Hinder MCO from Fully Accessing the PDMP to Curb FWA ................................................................. 84
Table 102 - Explanation for Barriers that Hinder MCO from Fully Accessing the PDMP to Curb FWA ................................ 84
Table 103 - Changes to State PDMP That Have Improved or Detracted from the Medicaid Program’s Ability to Access
PDMP Data ............................................................................................................................................................................ 85
Table 104 - Data or Privacy Breaches of PDMP or PDMP Data During This Reporting Period ............................................. 86
Table 105 - Opioid Category of Medications Carved Out and Handled by the State ........................................................... 87
Table 106 - POS Edit in Place to Limit the Days’ Supply Dispensed of an Initial Opioid Prescription for Opioid Naïve
Patients ................................................................................................................................................................................. 88
Table 107 - Maximum Number of Days Allowed for an Initial Opioid Prescription for Opioid Naïve Patients .................... 89
Table 108 - POS Edits in Place to Limit the Quantity Dispensed of Opioids ......................................................................... 90
Table 109 - POS Edits in Place to Limit the Quantity Dispensed of Short-Acting (SA) Opioids ............................................. 91
Table 110 - “Other” Explanations for POS Edits in Place to Limit the Quantity Dispensed of Short-Acting Opioids ........... 91
Table 111 - POS Edits in Place to Limit the Quantity Dispensed of Long-Acting Opioids ..................................................... 92
Table 112 - “Other” Explanations for POS Edits in Place to Limit the Quantity Dispensed of Long-Acting Opioids ............ 92
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Table 113 - Have Measures Other Than Restricted Quantities and Days’ Supply in Place to Either Monitor or Manage the
Prescribing of Opioids ........................................................................................................................................................... 93
Table 114- Measures other than Restricted Quantities and Days’ Supply in Place to Either Monitor or Manage the
Prescribing of Opioids ........................................................................................................................................................... 94
Table 115 - “Other” Explanations for Measures other than Restricted Quantities and Days’ Supply in Place to Either
Monitor or Manage the Prescribing of Opioids .................................................................................................................... 95
Table 116 - POS Edits to Monitor Duplicate Therapy of Opioid Prescriptions...................................................................... 96
Table 117 - POS Edits to Monitor Early Refills of Opioid Prescriptions Dispensed ............................................................... 97
Table 118 - Automated Retrospective Claim Reviews to Monitor Opioid Prescriptions in Excess of Program Limitations . 98
Table 119 - Scope, Nature, and Frequency of Retrospective Reviews of Opioid Prescription Monitoring in Excess of
Program Limitations .............................................................................................................................................................. 98
Table 120 - POS Edits or Automated Retrospective Claim Reviews to Monitor Opioids and Benzodiazepines Used
Concurrently ......................................................................................................................................................................... 99
Table 121 - Explanations of Scope and Nature of Reviews and Edits for Opioids and Benzodiazepines Being Used
Concurrently ......................................................................................................................................................................... 99
Table 122 - POS Edits or Automated Retrospective Claim Reviews to Monitor Opioids and Sedatives Being Used
Concurrently ....................................................................................................................................................................... 100
Table 123 - POS Edits or Automated Retrospective Claim Reviews to Monitor Opioids and Antipsychotics Being Used
Concurrently ....................................................................................................................................................................... 101
Table 124 - POS Safety Edits, Automated Retrospective Claims Reviews and/or Provider Education Regarding
Beneficiaries with a Diagnosis or History of OUD or Opioid Poisoning Diagnosis .............................................................. 102
Table 125 - POS Safety Edits, Automated Retrospective Claim Reviews and/or Provider Education Regarding Beneficiaries
with a Diagnosis or History of OUD or Opioid Poisoning Diagnosis .................................................................................... 103
Table 126 - Frequency of Automated Retrospective Reviews and/or Provider Education Regarding Beneficiaries with a
Diagnosis or History of OUD or Opioid Poisoning Diagnosis............................................................................................... 104
Table 127 - Provide Prescribers with Pain Management or Opioid Prescribing Guidelines ............................................... 105
Table 128 - Pain Management / Opioid Prescribing Guidelines Provided .......................................................................... 106
Table 129 - “Other Guidelines” Provided ............................................................................................................................ 106
Table 130 - Drug Utilization Management Strategy that Supports Abuse Deterrent Opioid Use ...................................... 107
Table 131 - “Yes” Explanation for Drug Utilization Management Strategy that Supports Abuse Deterrent Opioid Use ... 107
Table 132 - “No” Explanation for Drug Utilization Management Strategy that Supports Abuse Deterrent Opioid Use ... 107
Table 133 - COVID-19 Ramifications on Edits and Reviews on Controlled Substances During the Public Health Emergency
............................................................................................................................................................................................ 108
Table 134 - “Yes” Explanations for COVID-19 Ramifications on Edits and Reviews on Controlled Substances During the
Public Health Emergency .................................................................................................................................................... 108
Table 135 - MCO Recommended MME Daily Dose Measures ............................................................................................ 109
Table 136 - Maximum MME Daily Dose Limit in Milligrams ............................................................................................... 110
Table 137 - Explanations for Nature and Scope of Maximum MME Daily Dose Limit ........................................................ 110
T
able 138 - Edit in POS System that Alerts the Pharmacy Provider that the MME Daily Dose has been Exceeded .......... 111
Table 139 - Prior Authorization Required if MME Limit is Exceeded .................................................................................. 112
Table 140 - MCO Has Automated Retrospective Claim Reviews to Monitor MME Total Daily Dose ................................. 113
Table 141 - Provide Information to Prescribers to Calculate the MME Daily Dosage or Provide a Calculator Developed
Elsewhere ............................................................................................................................................................................ 114
Table 142 - Developer of the MME Daily Dosage Calculator .............................................................................................. 115
Table 143 - Information Dissemination Routes .................................................................................................................. 116
Table 144 - MCO Has Utilization Controls to Monitor/Manage Prescribing MAT Drugs for OUD ..................................... 117
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xiv | Page
Table 145 - Explanation for MCO Utilization Controls to Monitor/Manage Prescribing of MAT Drugs for OUD ............... 117
Table 146 - MCO Sets Total Milligram per Day Limits on the Use of Buprenorphine and Buprenorphine/Naloxone
Combination Drugs ............................................................................................................................................................. 118
Table 147 - Total Milligrams/Day Limit on the Use of Buprenorphine and Buprenorphine/Naloxone Combination Drugs
............................................................................................................................................................................................ 119
Table 148 - Limitations on Allowable Length of Treatment of Buprenorphine/Naloxone Combination Drugs ................. 120
Table 149 - Maximum Milligrams per Day Reduction After a Set Period of Time .............................................................. 121
Table 150 - Buprenorphine/Naloxone Combination Product Available Without Prior Authorization ............................... 122
Table 151 - Edits in Place to Monitor Opioids Being Used Concurrently with Any Buprenorphine Drug or Any Form of
MAT ..................................................................................................................................................................................... 123
Table 152 - POS Pharmacist Override Edit for Opioids Being Used Concurrently with Any Buprenorphine Drug or Any
Form of MAT ....................................................................................................................................................................... 124
Table 153 - Formulation of Naltrexone for OUD Available Without PA ............................................................................. 125
Table 154 - Naloxone Opioid Overdose Product Available Without PA ............................................................................. 126
Table 155 - Monitor and Manage Appropriate Use of Naloxone to Persons at Risk of Overdose .................................... 127
Table 156 - Explanation for Not Monitoring and Managing Appropriate use of Naloxone to Persons at Risk of Overdose
............................................................................................................................................................................................ 127
Table 157 - MCO Allows Pharmacists to Dispense Naloxone Prescribed Independently or by Collaborative Practice
Agreements, Standing Orders, Or Other Predetermined Protocols ................................................................................... 128
Table 158 - Explanation for MCO Allowing Pharmacists to Dispense Naloxone Prescribed Independently or By
Collaborative Practice Agreements, Standing Orders, Or Other Predetermined Protocols ............................................... 128
Table 159 - MCO Covers OTPs That Provide BH and MAT Through OTPs .......................................................................... 129
Table 160 - Referral Required for OUD Treatment Through OTPs ..................................................................................... 130
Table 161 - Explanation for Not Requiring Referrals for OUD Treatment Through OTPs .................................................. 130
Table 162 - MCO Covers Buprenorphine or Buprenorphine/Naloxone for Diagnoses of OUD as Part of a MAT Treatment
Plan...................................................................................................................................................................................... 131
Table 163 - MCO Covers Naltrexone for Diagnoses of OUD as Part of a MAT Treatment Plan ......................................... 132
Table 164 - MCO Covers Methadone for Substance Use Disorder ..................................................................................... 133
Table 165 - Restrictions to Limit Quantity of Antipsychotics .............................................................................................. 134
Table 166 - Explanations of Restrictions to Limit Quantity of Antipsychotics .................................................................... 134
Table 167 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Antipsychotic Drugs in
Children ............................................................................................................................................................................... 135
Table 168 - Categories of Children Either Managed or Monitored for Appropriate Use of Antipsychotic Drugs .............. 136
Table 169 - Edits in Place to Monitor the Appropriate Use of Antipsychotic Drugs in Children ........................................ 137
Table 170 - Child’s Age Limits for Edits in Place to Monitor the Appropriate Use of Antipsychotic Drugs in Children...... 137
Table 171 -
Other” Explanations for Edits in Place to Monitor the Appropriate Use of Antipsychotic Drugs in Children 137
Table 172 - Explanations of Specifics of Documented Antipsychotic Monitoring Program(s) ........................................... 138
Table 173 - Restrictions in Place to Limit the Quantity of Stimulant Drugs ........................................................................ 139
Table 174 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Stimulant Drugs in
Children ............................................................................................................................................................................... 140
Table 175 - Categories of Children Either Managed or Monitored for Appropriate Use of Stimulant Drugs .................... 141
Table 176 - Edits in Place to Monitor the Appropriate Use of Stimulant Drugs in Children ............................................... 142
Table 177 - Child’s Age Limits for Edits in Place to Monitor the Appropriate Use of Stimulant Drugs in Children ............ 142
Table 178 - “Other” Explanations for Edits in Place to Monitor the Appropriate Use of Stimulant Drugs in Children ...... 142
Table 179 - Explanations of Specifics of Documented Stimulant Monitoring Program(s) ................................................. 143
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Table 180 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Antidepressant Drugs in
Children ............................................................................................................................................................................... 144
Table 181 - Categories of Children Either Managed or Monitored for Appropriate Use of Antidepressant Drugs ........... 145
Table 182 - Edits in Place to Monitor the Appropriate Use of Antidepressant Drugs in Children ...................................... 146
Table 183 - Child’s Age Limits for Edits in Place to Monitor the Appropriate Use of Antidepressant Drugs in Children ... 146
Table 184 - “Other” Explanations for Edits in Place to Monitor the Appropriate Use of Antidepressant Drugs in Children
............................................................................................................................................................................................ 146
Table 185 - Explanations of Specifics of Documented Antidepressant Monitoring Program(s) ........................................ 147
Table 186 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Mood Stabilizing Drugs
in Children ........................................................................................................................................................................... 148
Table 187 - Categories of Children Either Managed or Monitored for Appropriate Use of Mood Stabilizing Drugs ......... 149
Table 188 - Edits in Place to Monitor the Appropriate Use of Mood Stabilizing Drugs in Children ................................... 150
Table 189 - Child’s Age Limits for Edits in Place to Monitor the Appropriate Use of Mood Stabilizing Drugs in Children 150
Table 190 - “Other” Explanations for Edits in Place to Monitor the Appropriate Use of Mood Stabilizing Drugs in Children
............................................................................................................................................................................................ 150
Table 191 - Explanations of Specifics of Documented Mood Stabilizer Monitoring Program(s) ........................................ 151
Table 192 - Documented Program in Place to Either Manage or Monitor the Appropriate Use of Antianxiety/Sedative
Drugs in Children ................................................................................................................................................................. 152
Table 193 - Categories of Children Either Managed or Monitored for Appropriate Use of Antianxiety/Sedative Drugs .. 152
Table 194 - Edits in Place to Monitor the Appropriate Use of Antianxiety/Sedative Drugs in Children ............................ 153
Table 195 - Child’s Age Limits for Edits in Place to Monitor the Appropriate Use of Antianxiety/Sedative Drugs in Children
............................................................................................................................................................................................ 153
Table 196 - “Other” Explanations for Edits in Place to Monitor the Appropriate Use of Antianxiety/Sedative Drugs in
Children ............................................................................................................................................................................... 153
Table 197 - Explanations of Specifics of Documented Antianxiety/Sedative Monitoring Program(s) ............................... 154
Table 198 - Demonstrations or Waivers to Allow Importation of Certain Drugs from Canada or Other Countries that are
Versions of FDA-Approved Drugs for Dispensing to Medicaid Beneficiaries ...................................................................... 155
Table 199 - Innovative Practices ......................................................................................................................................... 155
Table 200 - Executive Summary .......................................................................................................................................... 158
Georgia Medicaid MCO FFY 2022 DUR Annual Report
1 | Page
Section I - Demographic Information
1. On average, how many Medicaid beneficiaries are enrolled monthly in your MCO for this Federal
Fiscal Year?
Figure 1 - Number of Beneficiaries Enrolled in Each MCO
Table 1 - Number of Beneficiaries Enrolled in Each MCO
MCO Name
Number of Beneficiaries Enrolled
Amerigroup GA
588,809
CareSource
465,227
Peach State Health Plan
1,012,114
State Totals
2,066,150
0
200
400
600
800
1000
1200
Amerigroup GA CareSource Peach State Health Plan
# of Enrollees in Thousands
Georgia Medicaid MCO FFY 2022 DUR Annual Report
2 | Page
Section II - Prospective DUR (ProDUR)
1. Indicate the type of your pharmacy point of service (POS) vendor and identify it by name.
Figure 2 - Pharmacy POS Type of Vendor
Table 2 - Pharmacy POS Type of Vendor
Response
MCO Names
Count
Percentage
CareSource, Peach State Health Plan
2
66.67%
Amerigroup GA
1
33.33%
3
100%
Table 3 - Pharmacy POS Vendor Name
Response
MCO Names
Count
Percentage
Peach State Health Plan
1
33.33%
CareSource
1
33.33%
Amerigroup GA 1 33.33%
3
100%
Contractor, n=2
(67%)
Other Organization,
n=1 (33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
3 | Page
2. Identify ProDUR table driven criteria source (multiple responses allowed).
Figure 3 - Prospective DUR Criteria Source
Table 4 - Prospective DUR Criteria Source
Response
MCO Names
Count
Percentage
CareSource
1
25.00%
Amerigroup GA, Peach State Health Plan
2
50.00%
Peach State Health Plan
1
25.00%
4
100%
If “Other,” please specify.
Table 5 - “Other” Explanations for Prospective DUR Criteria Source
MCO Name
Explanation
Peach State Health Plan
CVS/Caremark
0
0.5
1
1.5
2
2.5
First Data Bank Medi-Span Other
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
4 | Page
3. When the pharmacist receives ProDUR alert message that requires a pharmacist’s review, does your
system allow the pharmacist to override the alert using the “National Council for Prescription Drug
Program (NCPDP) drug use evaluation codes” (reason for service, professional service and
resolution)?
Figure 4 - ProDUR Alert Message for Pharmacist Override using “NCPDP Drug Use Evaluation Codes”
Table 6 - ProDUR Alert Message for Pharmacist Override using “NCPDP Drug Use Evaluation Codes”
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
If “Yes” or “Varies by Alert Type,” check all that apply.
Table 7 - ProDUR Alert Types for Pharmacist Override
Response
MCO Names
Count
Percentage
with standard
Amerigroup GA, CareSource 2 50.00%
authorization (PA) to be
CareSource 1 25.00%
Peach State Health Plan
1
25.00%
4
100%
Varies by Alert
Type, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
5 | Page
If “Other,” please explain.
Table 8 - Explanation for OtherProDUR Alert Types for Pharmacist Override
MCO Name
Explanation
Peach State Health Plan
Generally this can be overridden with the exception of hard edits. Hard edits require a
request to be submitted to the Peach State Health Plan or the PBM for a review.
4. Does your MCO receive periodic reports providing individual pharmacy providers DUR alert override
activity in summary and/or in detail?
Figure 5 - Receives Periodic Reports Providing Individual Pharmacy Providers DUR Alert Override Activity
Table 9 - Receives Periodic Reports Providing Individual Pharmacy Provider DUR Alert Override Activity
Response
MCO Names
Count
Percentage
CareSource
1
33.33%
Amerigroup GA, Peach State Health Plan
2
66.67%
3
100%
No, n=2 (67%)
Yes, n=1 (33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
6 | Page
a. If “Yes,how often does your MCO receive reports (multiple responses allowed)?
Figure 6 - Frequency of Reports Providing Individual Pharmacy Provider DUR Alert Override Activity
Table 10 - Frequency of Reports Providing Individual Pharmacy Provider DUR Alerts Override Activity
Response
MCO Names
Count
Percentage
CareSource
1
100.00%
1
100%
0
0.2
0.4
0.6
0.8
1
1.2
Quarterly
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
7 | Page
b. If “Yes,” does your MCO follow up with those providers who routinely override with interventions?
Figure 7 - Follow up with Providers who Routinely Override with Interventions
Table 11 - Follow up with Providers who Routinely Override with Interventions
Response
MCO Names
Count
Percentage
CareSource
1
100.00%
1
100%
If “No,” please explain.
Table 12 - “No” Explanations for Receiving Periodic Reports Providing Individual Pharmacy Provider DUR Alert
Override Activity
MCO Name
Explanation
Amerigroup GA
We only receive a monthly denied claims report designated by denial reasons. Pro-DUR
denial reasons are included.
Peach State Health Plan
We do not routinely follow-up with pharmacy providers overriding interventions. DUR
intervention codes and trends are monitored at the edit level via POS detailed reports
that obtained monthly.
No, n=1 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
8 | Page
5. Early Refill
a. At what percent threshold does your MCO set your system to edit?
Figure 8 - Non-Controlled Drugs Early Refill Percent Edit Threshold
Figure 9 - Schedule II Controlled Drugs Early Refill Percent Edit Threshold
60
65
70
75
80
85
90
95
Amerigroup GA CareSource Peach State Health Plan
Percent Threshold
60
65
70
75
80
85
90
95
Amerigroup GA CareSource Peach State Health Plan
Percent Threshold
Georgia Medicaid MCO FFY 2022 DUR Annual Report
9 | Page
Figure 10 - Schedule III through V Controlled Drugs Early Refill Percent Edit Threshold
Table 13 - Early Refill Percent Threshold for Non-controlled and Controlled Drugs
MCO Name Non-controlled Drugs
Schedule II Controlled
Drugs
Schedule III through V
Controlled Drugs
Amerigroup GA
90.00%
90.00%
90.00%
CareSource
85.00%
90.00%
85.00%
Peach State Health Plan
80.00%
90.00%
90.00%
60
65
70
75
80
85
90
95
Amerigroup GA CareSource Peach State Health Plan
Percent Threshold
Georgia Medicaid MCO FFY 2022 DUR Annual Report
10 | Page
b. For non-controlled drugs, when an early refill message occurs, does your MCO require PA?
Figure 11 - Non-Controlled Drugs Early Refill Requirement for Prior Authorization
If “Yes” or “Dependent on medication or situation,” who obtains authorization?
Figure 12 - Non-Controlled Drugs Early Refill Authorization Sources
Yes, n=3 (100%)
Pharmacist or
Prescriber, n=2
(67%)
Prescriber, n=1
(33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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Table 14 - Non-Controlled Drugs Early Refill Requirement and Authorization Source for Prior Authorization
MCO Name
Non-controlled Early Refill
Prior Authorization?
If “Yes,” who obtains
authorization (Pharmacist,
Prescriber or Either)?
If “No,” can pharmacist
override at the point of
service?
Amerigroup GA
Yes
Prescriber
CareSource
Yes
Pharmacist or Prescriber
Peach State Health Plan
Yes
Pharmacist or Prescriber
c. For controlled drugs, when an early refill message occurs, does your MCO require PA?
Figure 13 - Controlled Drugs, Early Refill Requirement for MCO Prior Authorization
If “Yes,” who obtains authorization?
Figure 14 - Controlled Drugs Early Refill Authorization Source
Yes, n=3 (100%)
Pharmacist or
Prescriber, n=1
(33%)
Prescriber, n=2
(67%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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Table 15 - For Controlled Drugs, Early Refill Requirement and Authorization Source for Prior Authorization
MCO Name
Controlled Drugs Early
Refill Requirement for Prior
Authorization?
If “Yes,” who obtains
authorization? (Pharmacist,
Prescriber or Either)
IfNo,” can pharmacist
override at the point of
service?
Amerigroup GA
Yes
Prescriber
CareSource
Yes
Prescriber
Peach State Health Plan
Yes
Pharmacist or Prescriber
6. When the pharmacist receives an early refill DUR alert message that requires the pharmacist’s
review does your policy allow the pharmacist to override for situations such as (multiple responses
allowed):
Figure 15 - Policy Allows Pharmacist Overrides for an Early Refill
Table 16 - Policy Allows Pharmacist Overrides for an Early Refill
Response
MCO Names
Count
Percentage
CareSource
1
20.00%
CareSource
1
20.00%
Amerigroup GA, CareSource, Peach State Health Plan
3
60.00%
5
100%
If “Other,” please explain.
Table 17 - “Other” Explanations for Allowing Pharmacist Overrides for an Early Refill
MCO Name
Explanation
Amerigroup GA
Pharmacists must contact the PBM Help desk for a PA for lost/stolen Rx fill not more than
once every 6 months. Pharmacists can enter vacation overrides once per GPI14 every 180
days (twice per year).
0
0.5
1
1.5
2
2.5
3
3.5
Lost/stolen RX Other Vacation
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
13 | Page
MCO Name
Explanation
CareSource
Lost/stolen/vacation overrides can be done at point of sale by the pharmacist 1 time per
calendar year. This excludes controlled substances.
Peach State Health Plan
The pharmacist must contact Peach State Health Plan or the PBM for an override in the
above situations
7. Does your system have an accumulation edit to prevent patients from continuously filling
prescriptions early?
Figure 16 - System Accumulation Edit for Prevention of Early Prescription Filling
Table 18 - System Accumulation Edit for Prevention of Early Prescription Filling
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource
2
66.67%
Peach State Health Plan
1
33.33%
3
100%
If “Yes,” please explain your edit.
Table 19 - Explanations for System Accumulation Edit for Prevention of Early Prescription Filling
MCO Name
Explanation
Amerigroup GA
The refill thresholds for the following products are: Retail -- Refill Too Soon: 90%
Paper Claim -- Refill Too Soon: 90% Specialty -- Refill Too Soon: 75%
CareSource
Accumulation logic with a look back period of 90 days has a broader view of a patient's
history to more accurately determine if there is a potential stockpiling issue based on the
allowed day supply on hand.
No, n=1 (33%)
Yes, n=2 (67%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
14 | Page
If “No, does your MCO plan to implement this edit?
Figure 17 - Plans to Implement a System Accumulation Edit
Table 20 - Plans to Implement a System Accumulation Edit
Response
MCO Names
Count
Percentage
Peach State Health Plan
1
100.00%
1
100%
Yes, n=1 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
15 | Page
8. Does the MCO have any policy prohibiting the auto-refill process that occurs at the POS (i.e., must
obtain beneficiary’s consent prior to enrolling in the auto-refill program)?
Figure 18 - MCO Policy Prohibiting Auto-Refill at the POS
Table 21 - MCO Policy Prohibiting Auto-Refill at the POS
Response
MCO Names
Count
Percentage
Amerigroup GA
1
33.33%
CareSource, Peach State Health Plan
2
66.67%
3
100%
No, n=2 (67%)
Yes, n=1 (33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
16 | Page
9. Does your system have a diagnosis edit that can be utilized when processing a prescription?
Figure 19 - System Having a Diagnosis Edit That Can be Utilized When Processing Prescription
Table 22 - System Having a Diagnosis Edit That Can be Utilized When Processing Prescription
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
If “Yes,” please explain.
Table 23 - Explanations for System Having a Diagnosis Edit That Can be Utilized When Processing Prescription
MCO Name
Explanation
Amerigroup GA
Pharmacist can enter ICD-10 code to allow claim to pay or ICD-10 is found with the
diagnosis in the medical claim.
CareSource
CareSource sends medical diagnosis information to our PBM. Our PBM also ingests
diagnosis codes when the prescription is submitted at retail.
Peach State Health Plan
The DUR Diagnosis edit "messages" the pharmacist when contraindications based on
diagnosis is identified. The edit identifies contraindications based on the member's
diagnosis. These contraindications are classified as either absolute, potential or
precautionary
Yes, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
17 | Page
10. For drugs not on your MCO’s Preferred Drug List (PDL), does your MCO have a documented
process (i.e. PA) in place so that the Medicaid beneficiary or the Medicaid beneficiary’s prescriber
may access any covered outpatient drug when medically necessary?
Figure 20 - Documented Process for Beneficiaries or their Prescribers to Access Any Covered Outpatient Drug
(COD) when Medically Necessary
Table 24 - Documented Process for Beneficiaries or their Prescribers to Access Any Covered Outpatient Drug
(COD) when Medically Necessary
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
Yes, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
18 | Page
If “Yes,” please check all that apply.
Figure 21 - Documented Process in Place for Beneficiaries to Access Any Covered Outpatient Drug (COD) When
Medically Necessary
Table 25 - Documented Process in Place for Beneficiaries to Access Any Covered Outpatient Drug (COD) When
Medically Necessary
Response
MCO Names
Count
Percentage
diagnosis codes or
Amerigroup GA, CareSource, Peach State Health Plan 3 25.00%
Pharmacy and/or
CareSource, Peach State Health Plan 2 16.67%
CareSource, Peach State Health Plan 2 16.67%
Amerigroup GA, CareSource, Peach State Health Plan 3 25.00%
Amerigroup GA, Peach State Health Plan
2
16.67%
12
100%
If “Other,” please explain.
Table 26 - Explanations for “Other” Processes in Place for Beneficiaries to Access Any Covered Outpatient Drug
When Medically Necessary
MCO Name
Explanation
Amerigroup GA
Prescriber can also contact the PBM to request a PA by phone, fax or via the web (e-PA).
Peach State Health Plan
PA requests may be initiated by a member, a member's representative, or a member's
prescribing physician or other prescriber. These include, but are not limited to, requests
for medications that are non-formulary or have utilization management edits (such as
prior authorizations, step therapy requirements, or quantity limits).
0
0.5
1
1.5
2
2.5
3
3.5
Automatic PA Based on
Diagnosis Codes or
Systematic Review
Direct Involvement
With Pharmacy And/or
Medical Director
Other Pharmacist or
Technician Reviews
Trial and Failure of First
or Second-line
Therapies
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
19 | Page
a. How does your MCO ensure PA criteria is no more restrictive than the FFS criteria and review?
Table 27 - How MCO Ensures PA Criteria is No More Restrictive than FFS Criteria and Review
MCO Name
Description
Amerigroup GA
Where the State or health plan has delegated criteria management, we employ various
methods to ensure our criteria remains no more restrictive than the FFS. One of the
responsibilities of our specific market Pharmacist Program Manager is the continual
review of clinical criteria compared to State criteria to identify areas of opportunity and
maintain appropriate criteria. Our P&T Committee utilizes evidentiary standards
including FDA and official compendia, as well as, national clinical practice guidelines to
build our PA criteria. We work with the State that has established a process to review
MCO formulary. Periodically, we furnish our criteria for specific drug classes to the State
for parity review. We work directly with FFS or in workgroups on review and criteria
alignment. Additionally, we actively participate in all parity submissions to ensure there
are no more restriction on behavioral health drugs compared to physical health drugs.
CareSource
Caresource provides all new policies, and policy updates, for GA FFS to review and
approve prior to the policies going live.
Peach State Health Plan
All new policies, as well as existing prior authorization criteria changes, are reviewed
and approved to be consistent with current pharmaceutical and medical literature, peer
reviewed journals and professional standards of practice to support appropriate and
safe prescription drug use. Based on the FFS website and program descriptions, these
same resources are used during FFS' quarterly review of their own criteria. FFS will
periodically reach out to Peach State Health Plan to provide medication prior
authorization criteria and request Peach State Health Plan or the ensure their criteria is
not more restrictive.
b. Does your program provide for the dispensing of at least a 72-hour supply of a covered outpatient drug (COD) in
an emergency situation?
Figure 22 - Program Provides for the Dispensing of at least a 72-hour Supply of a COD in Emergency Situations
Yes, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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Table 28 - Program Provides for the Dispensing of at least a 72-hour Supply of a COD in Emergency Situations
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
If “Yes,please check all that apply.
Figure 23 - Process for the Dispensing of at least a 72-Hour Supply of CODs in Emergency Situations
Table 29 - Process for the Dispensing of at least a 72-Hour Supply of CODs in Emergency Situations
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource 2 50.00%
CareSource, Peach State Health Plan
2
50.00%
4
100%
If “Other process,please explain.
Table 30 - Explanations of “Other Processfor the Dispensing of at least a 72-Hour Supply of CODs in Emergency
Situations
MCO Name
Explanation
CareSource
A pharmacy may also call the pharmacy help desk for assistance if needed.
Peach State Health Plan
The beneficiary would contact Peach State Health Plan or the PBM and Peach State
Health Plan or the PBM will place an override providing a 72-hour supply for the
emergency situation.
0
0.5
1
1.5
2
2.5
Other Process Real Time Automated Process
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
21 | Page
11. Top Drug Claims Data Reviewed by the DUR Board:
Table 31 - Top Drug Claims Data Reviewed by the DUR Board*
Column 1
Top 10 Prior
Authorization (PA)
Requests by Drug
Name
Column 2
Top 10 PA Requests
by Drug Class
Column 3
Top 5 Claim Denial
Reasons (i.e. Quantity
Limits (QL), Early Refill
(ER), PA, Therapeutic
Duplications (TD), and
Age Edits (AE))
Column 4
Top 10 Drug Names
by Amount Paid
Column 5
Top 10 Drug Names by
Claim Count
Methylphenidate
Adhd Agents/
stimulants
Plan Limitations
Exceeded
Adalimumab Amoxicillin
Lisdexamfetamine
Attention Deficit
Hyperactivity
Disorder Agents
Dur Reject Error Dupilumab Albuterol
Dexmethylphenidate Antidiabetic Agents
Submit Bill To Other
Processor Or Primary
Payor
Elexacaftor/
tezacaftor/ ivacaftor
Ibuprofen
Guanfacine Dermatologicals Refill Too Soon
Bictegravir/
emtricitabine/
tenofovir
Loratadine
Atomoxetine Acne Therapy Ndc Not Covered Fluticasone Cetirizine
Dupilumab
Stimulants And
Related Agents
Methylphenidate Fluticasone
Tacrolimus
Calcitonin Gene-
related Receptor
Antagonist
Ustekinumab Methylphenidate
Test Strips
Diabetic Testing
Blood Glucose
Meters, Test Strips,
Lancets
Somatropin Azithromycin
Semaglutide
Proton Pump
Inhibitor Agents
Insulin Glargine
Dextroamphetamine/
amphetamine
Vyvanse
Anticonvulsant
Agents
Burosumab-twza Montelukast
* This table has been developed and formulated using weighted averages to reflect the relative beneficiary size of each
reporting MCO. Drug names are reported at the generic ingredient level.
Georgia Medicaid MCO FFY 2022 DUR Annual Report
22 | Page
Section III - Retrospective DUR (RetroDUR)
1. Please indicate how your MCO operates and oversees RetroDUR reviews.
Figure 24 - Operation and Oversight of RetroDUR Reviews
Table 32 - Operation and Oversight of RetroDUR Reviews
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
If “Other,” please explain.
Table 33 - “Other” Explanations for Operation and Oversight of RetroDUR Reviews
MCO Name
Explanation
Amerigroup GA
Combination of MCO and PBM executed RetroDUR activities.
CareSource
Combination of PBM and MCO
Peach State Health Plan
Peach State Health Plan or the PBM both execute retroDUR activities.
Other, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
23 | Page
2. Identify the vendor, by name and type, that performed your RetroDUR activities during the time
period covered by this report.
Figure 25 - Type of Vendor that Performed RetroDUR Activities
Table 34 - Type of Vendor that Performed RetroDUR Activities
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource
2
66.67%
Peach State Health Plan
1
33.33%
3
100%
Table 35 - Vendor Names
Response
MCO Names
Count
Percentage
Amerigroup GA 1 33.33%
Peach State Health Plan
1
33.33%
CareSource 1 33.33%
3
100%
Company, n=2 (67%)
Other Institution,
n=1 (33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
24 | Page
a. Is the RetroDUR vendor the developer/supplier of your retrospective DUR criteria?
Figure 26 - RetroDUR Vendor is the Developer/Supplier of Retrospective DUR Criteria
Table 36 - RetroDUR Vendor is the Developer/Supplier of Retrospective DUR Criteria
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
If “Yes,” please explain.
Table 37 - “YesExplanations for RetroDUR Vendor Developer/Supplier of Retrospective DUR Criteria
MCO Name
Explanation
Amerigroup GA
IngenioRx develops retroDUR programs and criteria specifically geared toward Medicaid
populations. Each program available is presented to the plan, and it is able to opt into
programs that fit its needs and membership.
CareSource
From October 2021 to December 2021 ESI's RationalMed identified members based on
clinical
algorithms and sent out recommendations to physicians and pharmacies.
Starting in 2022, CareSource worked collaboratively with our PBM's Academic Detailer to
develop rDUR criteria or developed criteria internally.
Peach State Health Plan
Peach State Health Plan works closely with the RetroDUR vendor to select programs that
meet the rDUR criteria.
Yes, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
25 | Page
b. Does your MCO customize your RetroDUR vendor criteria?
Figure 27 - MCO Customizes RetroDUR Vendor Criteria
Table 38 - MCO Customizes RetroDUR Vendor Criteria
Response
MCO Names
Count
Percentage
CareSource, Peach State Health Plan
2
66.67%
Amerigroup GA 1 33.33%
3
100%
Ad hoc Based on
State-specific
Needs, n=1 (33%)
Yes, n=2 (67%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
26 | Page
3. Who reviews and approves your MCO RetroDUR criteria?
Figure 28 - RetroDUR Criteria Approval/Review Sources
Table 39 - RetroDUR Criteria Approval/Review Sources
Response
MCO Names
Count
Percentage
Peach State Health Plan
1
33.33%
Amerigroup GA, CareSource
2
66.67%
3
100%
If “Other,” please explain.
Table 40 - “Other” Explanations RetroDUR Criteria Approval/Review Sources
MCO Name
Explanation
Amerigroup GA
Our DUR Board functions are handled by three committees, which include Pharmacy
Quality Programs (PQP), P&T, and Value Assessment (VAC) committees. PQP provides
feedback and approve newly proposed pharmacy quality or cost of care interventions or
changes to existing interventions upon request. P&T Committee reviews and approves
policies so they are optionally available for each business unit to use (or not) according to
their business needs. VAC decides to adopt a PA and makes drug list (PDL) decisions.
CareSource
From October 2021 to December 2021 PBM performed RetroDUR and had a clinical
review board and MCO initiated rDUR criteria was presented to the PBM clinical board.
Starting in 2022, MCO now reviews rDUR criteria internally.
MCO DUR Board,
n=1 (33%)
Other, n=2 (67%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
27 | Page
4. How often does your MCO perform retrospective practitioner-based education?
Figure 29 - Frequency of Retrospective Practitioner-Based Education
Table 41 - Frequency of Retrospective Practitioner-Based Education
Response
MCO Names
Count
Percentage
Amerigroup GA, Peach State Health Plan
2
66.67%
CareSource
1
33.33%
3
100%
If “Other,” please specify.
Table 42 - “Other” Frequency of Retrospective Practitioner-Based Education
MCO Name
Explanation
CareSource
Depending on the intervention and time sensitivity, the notifications can be sent weekly,
monthly or quarterly.
Monthly, n=2 (67%)
Other, n=1 (33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
28 | Page
a. How often does your MCO perform retrospective reviews that involve communication of client-specific
information to healthcare practitioners (multiple responses allowed)?
Figure 30 - Frequency of Retrospective Reviews that Involve Communication of Client-Specific Information to
Healthcare Practitioners
Table 43 - Frequency of Retrospective Reviews that Involve Communication of Client-Specific Information to
Healthcare Practitioners
Response
MCO Names
Count
Percentage
Monthly
Amerigroup GA, Peach State Health Plan
2
66.67%
Other
CareSource
1
33.33%
State Totals
3
100%
If “Other,” please specify.
Table 44 - “Other” Explanations for Frequency of Retrospective Reviews that Involve Communication of Client-
Specific Information to Healthcare Practitioners
MCO Name
Explanation
CareSource
Depending on the intervention and time sensitivity, the notifications can be sent weekly,
monthly or quarterly.
0
0.5
1
1.5
2
2.5
Monthly Other
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
29 | Page
b. What is the preferred mode of communication when performing RetroDUR initiatives (multiple responses
allowed)?
Figure 31 - Preferred Mode of Communication When Performing RetroDUR Initiatives
Table 45 - Preferred Mode of Communication When Performing RetroDUR Initiatives
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
27.27%
Amerigroup GA, CareSource, Peach State Health Plan
3
27.27%
non-direct provider
Amerigroup GA 1 9.09%
Amerigroup GA, CareSource, Peach State Health Plan
3
27.27%
CareSource
1
9.09%
11
100%
0
0.5
1
1.5
2
2.5
3
3.5
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
30 | Page
If “Other,” please specify.
Table 46 - “Other” Explanations for Preferred Mode of Communication When Performing RetroDUR Initiatives
MCO Name
Explanation
CareSource
RationalMed program sends messaging in near real time based on incoming pharmacy,
lab, and medical claims data.
5. Summary 1 - RetroDUR Educational Outreach
RetroDUR Educational Outreach Summary should be a year-end summary report on retrospective screening and
educational interventions. The summary should be limited to the most prominent problems with the largest number
of exceptions. The results of RetroDUR screening and interventions should be included and detailed below.
Table 47 - RetroDUR Educational Outreach
MCO Name
RetroDUR Educational Outreach Summary
Amerigroup GA
Summary 1 Retrospective DUR Educational Outreach Summary GA 2022 DUR
Date Range 10/1/21 9/30/22
New Start/New Start Depression
# Cases- 12109
# Unique Members- 12109
# Prescriber Messages Generated & Sent- 13142
# Member Messages Generated & Sent- 4
# Positive Outcomes- 4286
% Positive Impact- %39.47
Adherence/Adherence - ADHD Rx
# Cases- 10799
# Unique Members- 10799
# Prescriber Messages Generated & Sent- 0
# Member Messages Generated & Sent- 10814
# Positive Outcomes- 837
% Positive Impact- %10.22
Adherence/Adherence - Depression
Georgia Medicaid MCO FFY 2022 DUR Annual Report
31 | Page
MCO Name
RetroDUR Educational Outreach Summary
# Cases- 9442
# Unique Members- 9442
# Prescriber Messages Generated & Sent- 8000
# Member Messages Generated & Sent- 3683
# Positive Outcomes- 1380
% Positive Impact- %19.85
Adherence/Adherence - Asthma
# Cases- 8612
# Unique Members- 8612
# Prescriber Messages Generated & Sent- 7086
# Member Messages Generated & Sent- 3450
# Positive Outcomes- 714
% Positive Impact- %12
Adding Therapy/Needs Test - Asthma
# Cases- 6387
# Unique Members- 6387
# Prescriber Messages Generated & Sent- 4957
# Member Messages Generated & Sent- 2730
# Positive Outcomes- 294
% Positive Impact- %4.85
Adding Therapy/Needs Follow-Up - BH Meds
# Cases- 6349
# Unique Members- 6349
Georgia Medicaid MCO FFY 2022 DUR Annual Report
32 | Page
MCO Name
RetroDUR Educational Outreach Summary
# Prescriber Messages Generated & Sent- 0
# Member Messages Generated & Sent- 6358
# Positive Outcomes- 2899
% Positive Impact- %67.3
Adding Therapy/Needs Test - BH Meds
# Cases- 5580
# Unique Members- 5580
# Prescriber Messages Generated & Sent- 0
# Member Messages Generated & Sent- 5597
# Positive Outcomes- 1654
% Positive Impact- %34.14
Adherence/Adherence - Hypertension
# Cases- 5262
# Unique Members- 5262
# Prescriber Messages Generated & Sent- 4283
# Member Messages Generated & Sent- 2307
# Positive Outcomes- 767
% Positive Impact- %18.42
Medication Discontinuation/Antipsychotics in children < 18 years old
# Cases- 5095
# Unique Members- 5095
# Prescriber Messages Generated & Sent- 0
# Member Messages Generated & Sent- 5110
Georgia Medicaid MCO FFY 2022 DUR Annual Report
33 | Page
MCO Name
RetroDUR Educational Outreach Summary
# Positive Outcomes- 680
% Positive Impact- %13.51
New Start/New Start ADHD
# Cases- 4771
# Unique Members- 4771
# Prescriber Messages Generated & Sent- 4776
# Member Messages Generated & Sent- 2
# Positive Outcomes- 1981
% Positive Impact- %43.27
CareSource
10/1/2021 to 12/31/2021
RationalMed rDUR Activities - Top Safety Events by Volume Sent to Providers
- ADHD Stimulants, Mood and other Non-Psychotic Disorders
Unique Safety Events: 720
Success Rate: 54%
- Atypical Anti-psychotics & obesity/Weight gain (older than 18)
Unique Safety Events: 482
Success Rate: 57%
- Atypical Anti-psychotics (select) & suicidal ideation
Unique Safety Events: 325
Success Rate: 54%
- Atypical Anti-psychotics & Diabetes (21 and older)
Unique Safety Events: 283
Success Rate: 46%
- Polypharmacy (19 to 64 years old)
Unique Safety Events: 268
Success Rate: 41%
10/1/2021 to 9/30/2022
ADD Follow-Up: Provider outreach
- Telephonic outreach to improve follow-up appointment rates for children that are new
starts on ADHD medication, with provider outreach letters to provide Clinical Practice
Guidelines (CPGs), best treatment pearls for treatment, and to encourage coordination of
care between PCP and BH providers.
Providers involved: 1735
Providers agreed to recommendation: 1419
10/1/2021 to 9/30/2022
Opioid Rising Risk: Provider outreach letter
Georgia Medicaid MCO FFY 2022 DUR Annual Report
34 | Page
MCO Name
RetroDUR Educational Outreach Summary
- Outreach letter notifying provider of members at an increased risk of transitioning from
acute opioid use to chronic use.
Providers involved: 547
Percent of members who transitioned from acute to chronic opioid use:
i. 4Q21: 35.7%
ii. 1Q22: 39.3%
iii. 2Q22: 33.5%
2/16/2022 to 09/30/2022
Polypharmacy Consult
- Pharmacist polypharmacy medication review and provider consult for medication
recommendations
Members reviewed: 250
Average recommendation acceptance rate: 17%
4/27/2022
Sickle Cell Disease: Provider letters
- Provider outreach letters providing education on hydroxyurea and informing about
missing hydroxyurea therapy for patients
Providers contacted: 138
Recommendation acceptance rate: 8.7%
10/1/2021 to 9/30/2022
High MME: Provider outreach letter
- Provider outreach letter highlighting members' utilization of high dose opioids (greater
than 90 morphine milligram equivalents per day for 60 or more of the last 90 days) for the
treatment of chronic pain.
Providers involved: 92
9/20/2022
Academic Detailer: HIV PrEP
- Providers outreached by a clinical pharmacist and educated on Descovy, generic Truvada
indications and cost differences
Providers contacted: 8
Annual Savings or results: $55,928
11/23/2021
Academic Detailer: High-Cost Medications with a lower cost alternative
- Clinical pharmacist outreach to providers regarding lower cost metformin
Providers contacted: 3
Annual Savings or results: $15,781
7/15/2022
Academic Detailer: Cosentyx
- Providers outreached by a clinical pharmacist and encouraged to move patients from
single pack Cosentyx to two pack Cosentyx (cost for single vs two pack of Cosentyx is the
same)
Providers contacted: 1
Annual Savings or results: $17,523
Georgia Medicaid MCO FFY 2022 DUR Annual Report
35 | Page
MCO Name
RetroDUR Educational Outreach Summary
Peach State Health Plan
Peach State Health Plan identifies multiple gaps in therapy, underutilization or concerns in
treatment for members as outlined below. These programs were run in addition to our
Medication Therapy Management (MTM) program.
1. Retrospective Safety Review: Critical Drug-Drug Interactions To review POS Drug-
Drug Interactions alerts to address issues that were not addressed at the point of sale
within 72 hours of adjudication. A phone call or fax is sent to the provider alerting them
of this safety issue. Providers provided responses for these safety issues.
2. Controlled substances, and inappropriate use and misuse To reduce instances of
fraud, waste, and abuse of controlled substances through regular claims monitoring and
timely interventions.
3. Asthma Medication Management To identify members with an asthma diagnosis
who have filled a prescription for a controller inhaler. Telephonic outreach to members
to promote adherence to controller medications. After telephonic outreach, most
members are filling their asthma medications.
4. Antipsychotic Medication Management To identify members with a
schizophrenia or bipolar diagnosis who have filled a prescription for an antipsychotic
medication. Telephonic outreach to members to promote adherence to antipsychotic
medications. After telephonic outreach, most members are filling their antipsychotic
medications.
5. Multiple Opioid Prescribers To identify members who are either being fraudulent
or abusive with opioid analgesic medication. Create referral to the pharmacy lock-in
program for those meeting criteria. After referral, most of these members are placed into
pharmacy lock-in.
6. Attention Deficit Hyperactivity Disorder (ADHD) Treatment To identify members
who have received an initial prescription for ADHD medication. Telephonic outreach to
members and providers to promote follow up visits with prescriber and medication
adherence. After telephonic outreach, most members are filling their ADHD medications
and having follow-up prescriber visits.
7. Statin Use in Diabetes - To identify members who have diabetes who have been
prescribed statin therapy and their adherence to the statin therapy. Also, to identify
members who have diabetes who are not prescribed statin therapy. Telephonic outreach
to members and providers to promote adherence and statin therapy. After telephonic
outreach, most members are filling their statin medications.
8. Opioid Super-prescribers To identify opioid high prescribers. Provider letters are
mailed if they fall within the top 25% of prescribers or they have been identified as
prescribing opioids to at least 75% of their patients. Opioid claims per thousand have
decreased year over year.
Georgia Medicaid MCO FFY 2022 DUR Annual Report
36 | Page
Section IV - DUR Board Activity
1. Does your MCO utilize the same DUR Board as the State FFS Medicaid program or does your MCO
have its own DUR Board?
Figure 32 - MCO Utilizes the Same DUR Board as the State FFS Program or Has Own DUR Board
Table 48 - MCO Utilizes the Same DUR Board as the State FFS Program or Has Own DUR Board
Response
MCO Names
Count
Percentage
Peach State Health Plan 1 33.33%
Amerigroup GA, CareSource
2
66.67%
3
100%
If “Other,” please explain.
Table 49 - “Other” Explanations for MCO not Utilizing the Same DUR Board as the State FFS Program or its Own
DUR Board
MCO Name
Explanation
Amerigroup GA
Our DUR Board functions are handled by three committees which include Pharmacy
Quality Programs(PQP), P&T, and Value Assessment (VAC) committees. PQP provides
feedback and approve newly proposed pharmacy quality or cost of care interventions or
changes to existing interventions upon request. P&T Committee reviews and approves
policies so they are optionally available for each business unit to use (or not) according to
their business needs. VAC decides to adopt a PA, and makes drug list (PDL) decisions.
CareSource
During the reporting period, CareSource did not have a separate DUR Board. DUR
screening and intervention activities are outlined below.
MCO has its own
DUR Board, n=1
(33%)
Other, n=2 (67%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
37 | Page
2. Does your MCO have a Medication Therapy Management (MTM) Program?
Figure 33 - MCO has a Medication Therapy Management Program
Table 50 - MCO has a Medication Therapy Management Program
Response
MCO Names
Count
Percentage
CareSource, Peach State Health Plan
2
66.67%
Amerigroup GA
1
33.33%
3
100%
3. Summary 2 - DUR Board Activities
DUR Board Activities Summary should include a brief descriptive report on DUR activities during the fiscal year
reported.
Table 51 - DUR Board Activities
MCO Name
DUR Board Activities Summary
Amerigroup GA
Summary 2 DUR Board Activities
Amerigroup Georgia
DUR Board functions are handled by three committees, which include Pharmacy Quality
Programs (PQP), P&T, and Value Assessment (VAC) committees. PQP provides feedback
and approve newly proposed pharmacy quality or cost of care interventions or changes to
existing interventions upon request. P&T Committee reviews and approves policies so
they are optionally available for each business unit to use (or not) according to their
business needs. VAC decides to adopt a PA and makes drug list (PDL) decisions.
No, n=1 (33%)
Yes, n=2 (67%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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MCO Name
DUR Board Activities Summary
Retrospective Drug Utilization Review (RDUR) analysis is performed through a review of
administrative pharmacy claims each day, week, and/or month. RDUR letters are faxed or
mailed to targeted prescribers and members to identify gaps in care, discuss adherence
and identify cases of potential under-and over-utilization, drug abuse or misuse, and/or
improve formulary compliance. Some of these identified members are referred to the
Lock-in program or to a pharmacist for further evaluation or clinical intervention.
Additionally, our Clinical Pharmacy Care Center, composed of pharmacists and pharmacy
technicians conduct retrospective outreaches to members and providers. Examples of
these programs include evaluation of medications for polypharmacy and age
appropriateness, new start and adherence education, and opioid/controlled substance
management programs. State-specific program results are shared with the health plan
leaders at a minimum of a quarterly basis. RDUR details are also presented during plan-
specific Quality Management meetings and/or DUR Committee meetings.
Retrospective DUR programs are presented and approved by the Pharmacy Quality
Programs Committee. One purpose of the committee is to provide feedback and approve
newly proposed pharmacy quality or cost of care interventions or changes to existing
interventions upon request.
PQP Committee interventions approved on the following dates:
10/19/2021:
3 Month Specialty Split Fill Expansion: Shifting the current Specialty Split Fill program from
one month of two 14-or 15-day supply fills to three months of 14-or 15-day supply fills
using drugs from the existing list.
02/15/2022:
Accordant New Conditions 2022: Adding 3 new conditions (pulmonary arterial
hypertension, juvenile idiopathic arthritis, and inclusion body myositis) to the existing 19
specialty conditions that our vendor, Accordant, currently manages through the Specialty
Condition Management (SCM) enhanced program.
Follow-up Care for Children Prescribed ADHD Medication (ADD): New provider outreach
to ensure appropriate monitoring and follow-up for children that are new starts on ADHD
medications.
05/17/2022:
Medicaid Program Message Consolidation: Adding medication review rules to Medicaid
rule set and retire separate faxes for certain programs.
CareSource
During the reporting period, CareSource did not have a separate DUR Board. CareSource
engages with the MTM vendor to discuss DUR issues. These discussions end in
development of interventions to address identified issues through MTM interventions.
CareSource works with our PBM's Academic Detailer to identify DUR issues and
collaborate on provider outreach. We meet with our Academic Detailer on a weekly basis.
Georgia Medicaid MCO FFY 2022 DUR Annual Report
39 | Page
MCO Name
DUR Board Activities Summary
CareSource also worked with our PBM on prospective DUR edits. Any changes to
prospective DUR edits come from CareSource's internal P&T/VAC.
From 1/1/20 to 12/31/2021 CareSource adopted the ESI RationalMed Program that
contains over 4,000 potential rDUR opportunities. These rDUR opportunities are loaded
and trigger based on retrospective claims review. ESI has a DUR Board that decides on the
modifications of existing or addition of new interventions. RationalMed can send
interventions directly at the point of sale in real time. These interventions are based on
medical, lab, and prescription data.
CareSource also houses an internal clinical call center compromised of clinical
pharmacists and pharmacy technicians. This clinical call center works on various DUR
programs, such as monitoring psychotropic medication in children. These DUR programs
result in an outreach to the member and/or provider via telephone, fax, or letter.
Peach State Health Plan
Peach State Health Plan (PSHP) attends the Georgia Drug Utilization Board Meeting that is
held quarterly. The GA DUR Board reviews drug therapy, drug studies, and utilization
information. In FFY 2021, there were four GA DUR Board Meetings.
In addition to the GA DUR Board, there were 7 DUR MCO Board meetings (10/18/2021,
11/29/2021, 2/28/2022, 3/14/2022, 5/23/2022, 6/27/2022, 9/26/2022):
Prospective DUR - POS review:
During the reporting period, all cDUR messaging at the point of sale (POS) was reviewed
in the Pharmacy Drug Utilization Meeting. Edit types reviewed included the following:
Apparent Drug Misuse
Cumulative APAP Check
Cumulative Morphine Equivalent Dose
Dose Check Multiplier
Drug Age Precaution
Drug-Disease Precaution
Drug-Drug Interaction
Drug-Gender
Drug-Pregnancy
Excessive Controlled Substances: Multiple Drugs, Number of Therapies
Excessive Duration
High Dose
Ingredient Duplication
Low Dose
Therapeutic Duplication
Underuse Precaution
Buprenorphine-opioid concurrent use
Opioid claim >7 day supply in a nave member
Opiate/Benzodiazepines Drug Interaction
Refill Too Soon
Multiple Pharmacies
Multiple Prescribers
Duplicate Long Acting Opioids
All conflicts identified were determined to be appropriate.
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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MCO Name
DUR Board Activities Summary
Retrospective DUR:
To act as a safety net for situations that may have a negative clinical impact on a member.
Retail and mail prescriptions are reviewed daily for serious drug-to-drug interactions and
the prescriber is notified within 72 hours of claim processing. Providers are sent
therapeutic alerts via fax with patient profile requesting a response for an appropriate
intervention.
Goal:
Increase Member Safety
Increase Prescriber Engagement
Reduce Medication Error
The top Drug-Drug Interactions identified include:
OPIOIDS VS ANTIPSYCHOTICS
CITALOPRAM VS SELECTED ACID SUPPRESSION AGENTS
VARIOUS ANTICOAGULANTS VS NSAIDS
TRAMADOL VS VARIOUS AGENTS
TRIPTANS VS. SRIS
CLONIDINE VS BETA BLOCKERS
SELECTED CCBS VS BETA BLOCKERS
TIZANIDINE VS SELECTED H2RAS
SELECTED ANTICOAGULANTS VS ANTIPLATELET AGENTS
CLOPIDOGREL VS PPIS
Provider was sent letter within 72 hours of claim to alert them of DDI.
RetroDUR and ProDUR trends are monitored to identify opportunities and determine if
additional controls or interventions are needed- either prospectively or retrospectively
determined by each individual situation. A variety of rDUR projects have been conducted
from identified problems, and interventions have been made which may include
educational programs and/or other relevant interventions:
1) Diabetics medications and cardiovascular outcomes (Q1 2022)
Description/Goal: Patients with type 2 diabetes who are on DPP4 inhibitors and in whom
ASCVD or heart failure predominates, may see clinical benefit from utilizing GLP-1
receptor agonists and SGLT2 inhibitors. The goal of this DUR was to target patients who
may benefit from switching diabetes medication, and to also identify diabetic members
who are not on hypertension medications.
Intervention: member lists for those on DPP4s who have had cardiovascular events or
presence of ASCVD were created. Member lists for those with diabetes without an
ACEi/ARB were also created.
2) SABA Overutilization 2022 (Q1 2022)
Description/Goal: Short-Acting Beta Agonists (SABAs) are cornerstone rescue treatment
for asthma patients. However, overutilization of these inhalers can be common and may
indicate uncontrolled asthma. The 2021 GINA guidelines state that regular or frequent
use of SABA is associated with adverse effects and clinical outcomes. Goal was to ensure
members are utilizing SABA inhalers safely and appropriately, with considerations on
canister quantities per year as outlined in the 2021 GINA Asthma guidelines
Intervention: member lists for those utilizing 12 SABA inhalers for asthma were created.
Georgia Medicaid MCO FFY 2022 DUR Annual Report
41 | Page
MCO Name
DUR Board Activities Summary
3) Krystexxa Utilization (Q3 2022)
Description/Goal: Krystexxa is for the treatment of symptomatic hyperuricemia due to
chronic gout/gouty arthritis in patients refractory to conventional therapy. Now it is
recommended to be co-administered with methotrexate. This medication has specific
criteria in order to be utilized appropriately. The goal of this DUR was to ensure that
members are utilizing Krystexxa safely and appropriate and to determine whether
utilization management strategies need to be updated conducted at the health plan
Intervention: The majority of prior authorization cases were worked correctly upon
analysis. Medicaid corporate prior authorization policy was also evaluated and
recommendations to update were made to drug information team to finalize.
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Section V - Physician Administered Drugs (PAD)
The Deficit Reduction Act requires collection of nation drug code (NDC) numbers for covered outpatient physician
administered drugs. These drugs are paid through the physician and hospital programs. Has your pharmacy system
been designed to incorporate this data into your DUR criteria for:
1. ProDUR?
Figure 34 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
ProDUR
Table 52 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
ProDUR
Response
MCO Names
Count
Percentage
Amerigroup GA
1
33.33%
CareSource, Peach State Health Plan
2
66.67%
3
100%
No, n=2 (67%)
Yes, n=1 (33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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If “No, does your MCO have a plan to include this information in your DUR criteria in the future?
Figure 35 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR
Criteria for ProDUR
Table 53 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR
Criteria for ProDUR
Response
MCO Names
Count
Percentage
CareSource, Peach State Health Plan
2
100.00%
2
100%
No, n=2 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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2. RetroDUR?
Figure 36 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
RetroDUR
Table 54 - Incorporation of NDCs for Covered Outpatient Physician Administered Drugs into DUR Criteria for
RetroDUR
Response
MCO Names
Count
Percentage
Amerigroup GA
1
33.33%
CareSource, Peach State Health Plan
2
66.67%
3
100%
No, n=2 (67%)
Yes, n=1 (33%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
45 | Page
If “No, does your MCO have a plan to include this information in your DUR criteria in the future?
Figure 37 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR
Criteria for RetroDUR
Table 55 - Future Plans to Incorporate NDCs for Covered Outpatient Physician Administered Drugs into DUR
Criteria for RetroDUR
Response
MCO Names
Count
Percentage
CareSource, Peach State Health Plan
2
100.00%
2
100%
No, n=2 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
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Section VI - Generic Policy and Utilization Data
1. Summary 3 - Generic Drug Substitution Policies
Generic Drug Substitution Policies Summary should summarize factors that could affect your generic utilization
percentage. In describing these factors, please explain any formulary management or cost containment
measures, preferred drug list (PDL) policies, educational initiatives, technology or promotional factors, or other
State-specific factors that affect your generic utilization rate.
Table 56 - Generic Drug Substitution Policies
MCO Name
Generic Drug Substitution Policies Summary
Amerigroup GA
Our Prior Authorization and Health Plan Pharmacy Benefits policies address generic drug
substitution. To promote prescribing of safe and cost effective medications, a PA is
required for all non-formulary drugs, brand name medications with a generic equivalent,
drugs excluded from the pharmacy benefit/plan design, any drug that exceeds plan
limitations, and for drugs requiring clinical criteria. The health plan requires the use of
preferred generic or therapeutic equivalent alternative as medically necessary (where
applicable) prior to approval of non-formulary/non-preferred drugs. When or if there has
been a failure, contraindication, or intolerance to the specified alternatives, providers
must submit a PA request documenting the aforementioned events.
CareSource
CareSource follows Policy 0556 (RX-46-Pharmacy Generic and Formulary Management)
along with Procedure 0556.01 (RX-46-M-Pharmacy Generic and Formulary
Management). This allows for the processes below.
1. CareSource's PBM determines if a medication or pharmaceutical product will be
defined as a brand or generic medication in its claims processing system based on their
drug database.
2. New brand name medications are not automatically added to the PDL unless
otherwise indicated or required by State or Federal regulation. A review and approval by
the CareSource Pharmacy and Therapeutics (P&T) committee and Value Assessment
Committee is required to add these medications to the PDL, as covered in a separate
policy. New brand name medications are reviewed by the P&T Committee and VAC for
possible addition to the formulary after they have been on the market for at least six
months.
3. New generic medications may be added to the PDL as follows:
a. If the brand name equivalent is available on the PDL and does not have a prior
authorization requirement, the generic equivalent may be automatically added to the
PDL without a prior authorization requirement;
b. If the brand name equivalent is available on the PDL (i.e., "on formulary"), but with a
Prior Authorization requirement, the generic equivalent will also be added with the same
prior authorization requirement;
c. Any other circumstance will be presented to the P&T and VAC prior to addition;.
d. All decisions or recommendations for new generics will be presented to the P&T
committee and VAC at the next available meeting.
4. Brand name equivalent drugs (multi-source brands) will not be available on a
CareSource PDL except where required by regulation. Exceptions will be made for
medications used to treat epilepsy or other seizure disorder, after prior authorization is
submitted and approved.
Georgia Medicaid MCO FFY 2022 DUR Annual Report
47 | Page
MCO Name
Generic Drug Substitution Policies Summary
5. Any medication not available on a CareSource PDL is available upon Prior
Authorization request and approval for medical necessity by CareSource. Please refer to
appropriate Prior Authorization and Medical Necessity Policies.
6. Clinical Pharmacy Programs:
a. Therapeutic Interchange
i. CareSource encourages the use of preferred/formulary medications through use of a
closed formulary. This design requires a prior authorization for any product not on the
PDL.
ii. CareSource does not actively pursue therapeutic interchange, other than through the
use of a closed formulary benefit.
b. Quantity and Dose Limits
i. CareSource may implement dispensing limitations on medications and pharmaceutical
products based on quantity or dose to ensure the safe and effective use of medic
ii. Dispensing limits are based on FDA-approved dosing guidelines or other appropriate
compendia, as outlined in the "Off-Label Use" policy, and in accordance with and State
or Federal requirements, if appropriate.
c. Prior Authorization
i. CareSource may implement prior authorization requirements on medications and
pharmaceutical products to ensure appropriate use of medications
ii. Prior Authorization criteria are based on FDA-approved indications, relevant treatment
guidelines, clinical trials, or other appropriate compendia, as outlined in the "Off-Label
use" policy, and compendia and in accordance with and State or Federal requirements, if
appropriate.
d. Step Therapy
i. CareSource may implement step therapy requirements on medications and
pharmaceutical products to ensure appropriate and cost-effective use of medications
ii. Step Therapy criteria are based on preferred medications within a therapeutic
category or used to treat a particular condition; relevant treatment guidelines and
algorithms are considered as well
e. Exceptions for Non-preferred medications are subject to CareSource policy "Medical
Necessity for Non Formulary Medications"
f. In the event that a formulary benefit is found to be out of compliance with the Mental
Health Parity and Addiction Equity Act of 2008, CareSource will move expeditiously to
make the necessary changes in order to become in full compliance with the MHPAEA.
g. Members and Providers are able to access the State-specific Preferred Drug List on the
web at www.caresource.com. These lists are updated quarterly in accordance with
CareSource/Communications standard operating procedures. Members who are affected
by a formulary change will be notified in writing 30 days in advance of the formulary
change. Prescribing
practitioners will receive notice via the Drug Formulary Changes posted on the pharmacy
page of the provider website. The Preferred Drug list and List of Medication that require
Prior Authorization will be updated after changes are made each quarter and will be
posted on the website.
Peach State Health Plan
Brand name drugs require review prior to approval. A generic drug is identical and
bioequivalent to a brand name drug in dosage form, safety, strength, route of
administration, quality, performance characteristics, and intended use. Generic
substitution is mandatory for Peach State Health Plan when A-rated generic equivalents
are available; however, brand name drugs may be approved in certain circumstances
where there are adverse reactions to or therapeutic failure of generic drugs. If a
Georgia Medicaid MCO FFY 2022 DUR Annual Report
48 | Page
MCO Name
Generic Drug Substitution Policies Summary
physician/clinician provider feels a brand name drug is medically necessary, the
physician/clinician can ask for PA.
PROCEDURE:
Request for Brand Name Drug in Lieu of Generic Formulation (must meet all):
1. Prescribed indication is FDA-approved;
2. Failure of an adequate trial of or clinically significant adverse effects to two generics
(each from a different manufacturer) or the preferred biosimilar(s) of the requested
brand name drug, unless member has contraindications to the excipients in all
generics/biosimilars;
3. If clinically significant adverse effects were experienced, provider submits chart note
documentation;
4. Provider submits clinical rationale supporting why the brand name drug will be more
effective than the generic or will not produce the same adverse effects as the generic;
5. Request meets one of the following (a or b):
a. Dose does not exceed the FDA approved maximum recommended dose for the
relevant indication and health plan approved daily quantity limit;
b. Dose is supported by practice guidelines or peer-reviewed literature (prescriber must
submit supporting evidence).
2. In addition to the requirement that the prescriber write in his own handwriting “Brand Medically
Necessary” for a brand name drug to be dispensed in lieu of the generic equivalent, does your MCO
have a more restrictive requirement?
Figure 38 - More Restrictive MCO Requirements than the Prescriber Writing in His Own Handwriting “Brand
Medically Necessary” for a Brand Name Drug
Yes, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
49 | Page
Table 57 - More Restrictive MCO Requirements than the Prescriber Writing in His Own Handwriting “Brand
Medically Necessary” for a Brand Name Drug
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
If “Yes, check all that apply.
Figure 39 - Additional Restrictive MCO Requirements for Dispensing a Brand Name Drug
Table 58 - Additional Restrictive MCO Requirements for Dispensing a Brand Name Drug
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
42.86%
MedWatch Form be
CareSource 1 14.29%
reason(s) for override
accompany the
CareSource 1 14.29%
CareSource, Peach State Health Plan
2
28.57%
7
100%
If “Other,” please explain.
Table 59 - “Other” Explanations for Additional Restrictive MCO Requirements for Dispensing a Brand Name Drug
MCO Name
Explanation
CareSource
DAW 1 (Dispense As Written) overrides are systematically allowed for narrow therapeutic
index medications without prior authorization when pharmacy enters DAW 1.
Peach State Health Plan
Prescriber must indicate "Brand Medically Necessary" on the prescription.
0
0.5
1
1.5
2
2.5
3
3.5
Other PA is Required Require That a MedWatch
Form be Submitted
Require the Medical
Reason(s) for Override
Accompany the
Prescription(s)
# MCOs
Georgia Medicaid MCO FFY 2022 DUR Annual Report
50 | Page
Generic Drug Utilization Data
Computation Instructions KEY
Single Source (S) Drugs having an FDA New Drug Application (NDA), and there are no generic alternatives
available on the market.
Non-Innovator Multiple-Source (N) Drugs that have an FDA Abbreviated New Drug Application (ANDA), and
generic alternatives exist on the market
Innovator Multiple-Source (I) Drugs which have an NDA and no longer have patent exclusivity.
1.
Generic Utilization Percentage: To determine the generic utilization percentage of all covered outpatient
drugs paid during this reporting period, use the following formula:
N ÷ (S + N + I) × 100 = Generic Utilization Percentage
2.
Generic Expenditure Percentage: To determine the generic expenditure percentage (rounded to the
nearest $1000) for all covered outpatient drugs for this reporting period use the following formula:
$N ÷ ($S + $N + $I) × 100 = Generic Expenditure Percentage
CMS has developed an extract file from the Medicaid Drug Rebate Program Drug Product Data File identifying each
NDC along with sourcing status of each drug: S, N, or I.
Figure 40 - Total Single Source (S) Drug Claims by MCO
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Amerigroup GA CareSource Peach State Health Plan
# Drug Claims
Georgia Medicaid MCO FFY 2022 DUR Annual Report
51 | Page
Figure 41 - Total Non-Innovator (N) Drug Claims by MCO
Figure 42 - Total Innovator Multi-Source (I) Drug Claims by MCO
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
Amerigroup GA CareSource Peach State Health Plan
# Drug Claims
0
50,000
100,000
150,000
200,000
250,000
300,000
Amerigroup GA CareSource Peach State Health Plan
# Drug Claims
Georgia Medicaid MCO FFY 2022 DUR Annual Report
52 | Page
Table 60 - Generic Drug Utilization Data: Single Source Innovator(S), Innovator Multiple-Source (I), Non-Innovator
Multiple-Source (N)
MCO Name “S” Drug Claims “N” Drug Claims “I” Drug Claims
Amerigroup GA
124,316
2,540,963
156,400
CareSource 80,479 2,114,697 107,895
Peach State Health Plan
166,365
4,334,363
257,063
State Totals
371,160
8,990,023
521,358
3. Indicate the generic utilization percentage for all CODs paid during this reporting period.
Figure 43 - Generic Utilization Percentage
Table 61 - Generic Utilization Percentage
MCO Name Generic Utilization Percentage
Amerigroup GA 90.05%
CareSource
91.82%
Peach State Health Plan
91.10%
State Average
90.99%
0
10
20
30
40
50
60
70
80
90
100
Amerigroup GA CareSource Peach State Health Plan
Generic Utilization Percentage
Georgia Medicaid MCO FFY 2022 DUR Annual Report
53 | Page
4. How many innovator drugs are the preferred product instead of their multi-source counterpart
based on net pricing (i.e. brand name drug is preferred over equivalent generic product on the
PDL)?
Figure 44 - Innovator Drugs That Are The Preferred Product Instead Of Their Multi-Source Counterpart Based On
Net Pricing
Table 62 - Innovator Drugs That Are The Preferred Product Instead Of
Their Multi-Source Counterpart Based On Net Pricing
MCO Name Preferred Drug Product Count
Amerigroup GA
0
CareSource 21
Peach State Health Plan
0
0
5
10
15
20
25
Amerigroup GA CareSource Peach State Health Plan
Preferred Drug Product Count
Georgia Medicaid MCO FFY 2022 DUR Annual Report
54 | Page
5. Indicate the percentage dollars paid for generic CODs in relation to all COD claims paid during this
reporting period.
Figure 45 - Percentage Dollars Paid for Generic CODs
Table 63 - Percentage Dollars Paid for Generic CODs
MCO Name Generic Expenditure Percentage
Amerigroup GA 21.65%
CareSource
22.66%
Peach State Health Plan
22.47%
State Average
22.26%
6. Does your MCO have any policies related to Biosimilars?
Table 64 - Explanations for MCO Policies Related to Biosimilars
MCO Name
Explanations
Amerigroup GA
We cover biosimilar agents in the same manner as the reference product. The biosimilar
agents are specifically called out in the clinical criteria. Biosimilar agents are at parity
with the reference agents with regard to allowed indications.
CareSource
No, biosimilars are reviewed as individual products.
Peach State Health Plan
Biosimilar utilization requirements are built into each respective drug policy where a
biosimilar drug exists. These policies may require utilization of the biosimilar drug prior
to approval of the legend drug unless adverse events or contraindications exist to
biosimilar drugs.
0
5
10
15
20
25
Amerigroup GA CareSource Peach State Health Plan
Generic Expenditure Percentage
Georgia Medicaid MCO FFY 2022 DUR Annual Report
55 | Page
7. Does your Medicaid program provide coverage of over-the-counter medications when prescribed by
an authorized prescriber?
Figure 46 - Medicaid Program Providing Coverage of Over-the-Counter Medications When Prescribed by an
Authorized Prescriber
Table 65 - Medicaid Program Providing Coverage of Over-the-Counter Medications When Prescribed by an
Authorized Prescriber
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
Yes, n=3 (100%)
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Section VII - Fraud, Waste and Abuse Detection (FWA)
A. Lock-in or Patient Review and Restriction Programs
1. Does your MCO have a documented process in place that identifies potential FWA of controlled
drugs by beneficiaries?
Figure 47 - Documented Process in Place to Identify Potential FWA of Controlled Drugs by Beneficiaries
Table 66 - Documented Process in Place to Identify Potential FWA of Controlled Drugs by Beneficiaries
Response
MCO Names
Count
Percentage
Amerigroup GA, CareSource, Peach State Health Plan
3
100.00%
3
100%
Yes, n=3 (100%)
Georgia Medicaid MCO FFY 2022 DUR Annual Report
57 | Page
If “Yes,” what actions does this process initiate (multiple responses allowed)?
Figure 48 - Actions Process Initiates when Potential FWA of Controlled Drugs by Beneficiaries is Detected
Table 67 - Actions Process Initiates when Potential FWA of Controlled Drugs by Beneficiaries is Detected
Response
MCO Names
Count
Percentage
Amerigroup GA, Peach State Health Plan
2
22.22%
Amerigroup GA, CareSource, Peach State Health Plan
3
33.33%
CareSource 1 11.11%
Integrity Unit (PIU)
and/or Surveillance
Utilization Review (SUR)
Unit for
CareSource, Peach State Health Plan 2 22.22%
Peach State Health Plan 1 11.11%
9
100%
0
0.5
1
1.5
2
2.5
3
3.5
Deny Claims Refer to Lock-In
Program
Refer to Office of
Inspector General (OIG)