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Enhanced Medicaid Drug Review Requirements

Posted in Drug Pricing

On August 5, the Centers for Medicare & Medicaid Services (CMS) released new guidance for states and Medicaid managed care programs to update their two-phase Medicaid drug utilization review programs to screen drug claim data in order to identify patterns of abuse. As explained in the CMS press release, “The guidance will help states implement drug use review procedures newly required under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act), so state Medicaid programs can better monitor opioid prescribing and dispensing patterns, including new requirements for states to implement electronic notifications, also known as safety edits. These notifications can alert health care professionals, such as pharmacists, of potential concerns with a medication prescribed for the patient that has to be resolved before it can be dispensed and safely taken by the patient.” See. These new CMS mandates apply equally to state Medicaid fee for service programs and private managed care companies. States have until Dec. 31, 2019 to outline their state plan amendments to overhaul the way they approach opioid use by their Medicaid populations.

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