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TRICARE Operations Manual 6010.59-M, April 1, 2015
Prescription Monitoring Program (PMP)
Chapter 28
Section 1
General
Revision:  C-66, July 2, 2020
For the purpose of this section, the term “contractor” applies to the Managed Care Support (MCS) contractor and Uniformed Services Family Health Plan (USFHP) Designated Providers (DPs).
1.0  Scope
1.1  The PMPs are quarterly reviews of all beneficiaries who received prescriptions and all providers who prescribed controlled substances prescriptions, such as opioids, using TRICARE benefits.
•  The Beneficiary PMP applies to the contractors and TRICARE Pharmacy (TPharm) contractor. The Provider PMP applies to the contractors. USFHPs are required to administer like programs using their own data.
•  TRICARE Overseas Program (TOP) contractor shall administer a like program for both the Beneficiary and Provider PMP using their own data and shall be excluded from quarterly reporting but may be contacted as necessary.
•  TRICARE For Life (TFL) contractor shall be excluded from quarterly reporting but may be contacted as necessary to resolve non-routine cases.
•  The Department of Veterans Affairs (VA)/Veterans Health Administration (VHA) is excluded from quarterly reporting but may be contacted to resolve non-routine cases.
•  Dental programs shall be excluded from the beneficiary quarterly reporting but may be contacted to resolve non-routine cases involving beneficiary use and provider prescribing.
•  Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs) will receive data of persons for whom the MTF/eMSM is (or acts as) a Primary Care Manager (PCM), but are not required to participate in these programs (for details refer to DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract).
•  Any contractor or MTF/eMSM may use the restriction portions of the programs at their discretion.
1.2  The PMPs perform automated reviews using predefined algorithms to identify beneficiaries with a higher use of controlled substances (Schedule II-V) than parameter thresholds, and TRICARE providers who prescribe a higher use of controlled substances (Schedule II-V), such as opioids, to beneficiaries above parameter thresholds. Other non-controlled substances may be included if they are known to be combined with Schedule II-V for purposes of substance abuse. The results will be sent to the appropriate contractor based upon beneficiary’s PCM assignment (Prime) or location (Select), or provider’s location for review.
1.3  All communication and coordination will comply with Health Insurance Portability and Accountability Act (HIPAA) standards.
2.0  Authority
2.1  The 32 CFR 199.4(e)(11) states that:
“TRICARE benefits cannot be authorized to support or maintain an existing or potential drug abuse situation whether or not the drugs (under other circumstances) are eligible for benefit consideration and whether or not obtained by legal means. Drugs, including the substitution of a therapeutic drug with addictive potential for a drug of addiction, prescribed to beneficiaries undergoing medically supervised treatment for a Substance Use Disorder (SUD) as authorized under paragraph (e)(4)(ii) of this section are not considered to be in support of, or to maintain, an existing or potential drug abuse situation and are allowed.”
This does not preclude payment for medically necessary services.
2.2  Each of the contractors and the TPharm contractor shall implement utilization control and quality measures designed to identify possible drug abuse situations. Each contractor shall screen all claims within their system for medication line items that show potential over-utilization and medically inappropriate prescribing of drugs, and subject any such cases to an extensive review to establish the necessity for the drugs and their appropriateness on the basis of diagnosis or definitive symptoms. These programs supplement the objective of the Code of Federal Regulations (CFR) language and are not meant to be the sole means of utilization control.
3.0  Suspension, Denial, and Recoupment of Claims
3.1   32 CFR 199.4(e)(11)(iv) states:
“(A) When a possible drug abuse situation is identified, all claims for drugs for that specific beneficiary or provider will be suspended pending the results of a review.
(B) If the review determines that a drug abuse situation does in fact exist, all drug claims held in suspense will be denied.
(C) If the record indicates previously paid drug benefits, the prior claims for that beneficiary or provider will be reopened and the circumstances involved reviewed to determine whether or not drug abuse also existed at the time the earlier claims were adjudicated. If drug abuse is later ascertained, benefit payments made previously will be considered to have been extended in error and the amounts so paid recouped.
(D) Inpatient stays primarily for the purpose of obtaining drugs and any other services and supplies related to drug abuse also are excluded.”
3.2  It is not the intent of the programs to restrict care for legitimate medical purposes. The contractors shall develop evidence-based criteria, incorporating national standards of care for identifying diagnoses and/or protocols for medically necessary services, in an effort to clearly determine non-drug seeking behavior and pay claims appropriately for non-drug seeking behavior.
4.0  POTENTIAL FRAUD
The contractor and TPharm contractor shall not submit these cases to the Defense Health Agency (DHA) Program Integrity (PI) office unless potential fraud or patient harm is identified, such as altered prescriptions or drug receipts, or aberrant prescribing patterns by the provider (e.g., prescribing without a legitimate medical purpose, such as no medical examination(s) by the prescribing clinician(s)), patient harm, or potential drug diversion scenarios. When appropriate, the contractor and TPharm contractor shall develop the case as stated in Chapter 13, Section 3.
5.0  REPORTS
In addition to the quarterly reports, summary reports shall be generated to support the programs.
6.0  Beneficiary and Provider PMPs
6.1  See Section 1 for the Beneficiary PMP.
6.2  See Section 3 for the Provider PMP.
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