TRICARE Operations Manual 6010.62-M, April 2021 Prescription Monitoring Program (PMP) Chapter 28 Section 1 General Revision: For the purpose of this section, the term ‘contractor’ applies to the Managed Care Support Contractor (MCSC) and Uniformed Services Family Health Plan (USFHP) Designated Providers (DPs). The term ‘TPharm contractor’ applies only to the TRICARE Pharmacy (TPharm) contractor. 1.0 Scope1.1 The Prescription Monitoring Programs (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 TPharm contractor. The provider PMP applies to the contractors. USFHPs are required to administer like programs using their own data and report as required in Section 3. • TRICARE Overseas Program (TOP) contractor is required to administer a like program for both the beneficiary and provider PMP using their own data and is excluded from quarterly reporting but may be contacted as necessary. • TRICARE Medicare Eligible Program (TMEP) contractor is excluded from quarterly reporting but may be contacted as necessary to resolve non-routine cases. • The Department of Veterans Affairs/Veterans Health Administration (DVA/VHA) is excluded from quarterly reporting but may be contacted to resolve non-routine cases. • TRICARE Dental Program (TDP) and TRICARE Active Duty Dental Program (ADDP) contractors are excluded from the beneficiary quarterly reporting but may be contacted to resolve non-routine cases involving beneficiary use and provider prescribing. • Markets/Military Medical Treatment Facilities (MTFs) will receive data of persons for whom the Market/MTF is (or acts as) a Primary Care Manager (PCM), but are not required to participate in these programs. • Any contractor or Market/MTF may use the restriction portions of the programs at their discretion. 1.2 All communication and coordination will comply with Health Insurance Portability and Accountability Act (HIPAA) standards. 2.0 AUTHORITY2.1 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.” 2.2 This does not preclude payment for medically necessary services. 2.3 The contractor and the TPharm contractor shall implement utilization control and quality measures designed to identify possible drug abuse situations. 2.4 The contractor shall screen all claims within its system for medication line items that show potential over-utilization and medically inappropriate prescribing of drugs, and to 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. 2.5 This program is to supplement the objective of the Code of Federal Regulations (CFR) language and not meant to be the sole means of utilization control. 3.0 SUSPENSION, DENIAL, AND RECOUPMENT OF CLAIMS3.1 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 program to restrict care for legitimate medical purposes. 3.3 The contractor 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 QUALITY ASSURANCE4.1 POTENTIAL QUALITY ISSUE (PQI)The contractor shall, based upon the outcome of the review, refer any PQIs as stated in Chapter 7, Section 6. 4.2 POTENTIAL FRAUD4.2.1 The contractor and TPharm contractor shall not submit cases to the Defense Health Agency (DHA) Program Integrity Office (PI) 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. 4.2.2 The contractor and TPharm contractor, when appropriate, shall develop the case as stated in Chapter 13, Section 4. - END -