TRICARE Manuals - Display Chap 28 Sect 2 (Change 13, Aug 22, 2024)

Prescription Monitoring Program (PMP)

Chapter 28

Section 2

Beneficiary Prescription Monitoring Program (PMP)

Revision:

For the purpose of this section, the term “contractor” applies to the Managed Care Support Contractor (MCSC). The term “TPharm contractor” applies only to the TRICARE Pharmacy (TPharm) contractor.

1.0 Goal

The goal of the program is to identify beneficiaries who may need additional medical assistance by providing knowledge of resources and maintaining compliance with the guidelines described within 32 CFR 199.4.

2.0 INITIAL REVIEW AND SUPPORT SERVICES

2.1 Beneficiary Identification

2.1.1 The TPharm contractor shall, on a quarterly basis, generate for every contractor and Market/Military Medical Treatment Facility (MTF), a list of all beneficiaries surpassing the current established parameters, to include the use of opioid potentiators. The TPharm contractor shall base the parameters upon pharmacy’s commercial best practices for identifying potential Substance Use Disorder (SUD) and doctor shopping. The TPharm contractor shall not make these parameters publicly available.

2.1.2 The TPharm contractor shall communicate the parameters to the Government and identify when changes are necessary.

2.1.3 The TPharm contractor shall send reports to the contractors and Market/MTF for medical review. See paragraph 5.0 for reports.

2.1.4 The TPharm contractor shall refer the identified beneficiaries to the appropriate contractor, if during the quarter concerns about controlled substance use are identified by other entities such as private providers (physician, nurse practitioners, etc.) or reviewers in the course of business.

2.2 Beneficiary Review

2.2.1 The contractor shall prioritize and review a minimum of 20 beneficiary cases per quarter from the quarterly list. See paragraph 2.4 for appropriate responses, and paragraph 2.5 for responses that count towards the minimum review.

2.2.2 The contractor shall designate a “reviewer”. The reviewer shall be a contractor’s Chief Medical Officer (CMO) or a person approved by the CMO. The contractor’s reviewer shall:

2.2.2.1 Have the appropriate credentials to review all types of claims;

2.2.2.2 Review individuals on the quarterly list and make determinations based upon the beneficiaries’ entire profile regardless of individual providers seen over the duration of the report; and

2.2.2.3 Conduct a medical review of the patient history to validate utilization with medical diagnosis and appropriateness of care and incorporate:

2.2.2.3.1 The level of review necessary is the breadth and depth needed to make an accurate determination; and

2.2.2.3.2 Other relevant information as necessary to make an accurate determination to include but not limited to claims review or record review.

2.2.3 The contractor shall, if there are any inconsistencies with utilization and medical diagnosis or over-utilization concerns for medical diagnosis noted by the reviewer, develop a support plan. The contractor’s support plan shall include:

2.2.3.1 Contractually available services, such as case management, pain management, behavioral health; or

2.2.3.2 Restrictions and contractually available services as described in paragraph 3.0; or

2.2.3.3 Restrictions only.

2.2.4 The contractor shall, if the plan includes restrictions, notify the TPharm contractor and the TPharm contractor shall begin the process outlined in paragraph 3.0.

2.2.5 The contractor shall, if the contractor is notified during the quarter concerns about controlled substance use are identified by another entity, to include but not limited to, the TPharm contractor or private providers (e.g., physician, nurse practitioner, etc.) or the contractor’s reviewers in the course of business:

2.2.5.1 Place individuals identified on 100% prepayment review and conduct a medical review by the contractor’s reviewer as received to determine final status; and

2.2.5.2 Give identified individuals placed on medical review priority over the quarterly list.

2.2.5.3 The Government may include these individuals towards the contractor’s minimum 20 cases per quarter (see paragraph 2.2.1) based on the contractor’s response.

2.3 The TPharm contractor shall coordinate cases that need assistance from the Markets/MTFs.

2.4 The contractor shall provide a response in the following manner for reviewed beneficiaries:

• No Action (diagnosis supports utilization)

• Support plan with restrictions

• Support plan without restrictions

• Restrictions Only

• Further monitoring needed

• Not Reviewed

2.5 The Government will only count beneficiaries documented as no action, support plan with or without restrictions, or restrictions only towards for cases reviewed.

2.6 The contractor shall provide responses to the Government within 60 calendar days after receiving the TPharm report identifying at-risk beneficiaries and upload to the Performance Assessment Tracker (PAT) tool (for details refer to DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract) and provide a courtesy copy to the Government’s designated pharmacy point of contact.

2.7 The contractor shall coordinate efforts with other TRICARE contractors as needed (change in PCMs, change in regions) to ensure the beneficiary’s care is appropriately managed and benefits are not being abused.

2.8 The TPharm contractor shall use the responses to generate a new report for the next quarter and be documented on future reports for trending across quarters.

3.0 RESTRICTIONS

3.1 For beneficiaries documented with either a support plan with restrictions or restrictions only:

3.1.1 The contractor shall notify the TPharm contractor regarding which beneficiaries to add to the restriction program.

3.1.2 Unless the contractor chooses to specify more stringent restrictions, the TPharm contractor shall implement the default restriction. See paragraphs 3.2.2 to 3.2.4 for available restriction options.

3.1.3 The contractor shall restrict medication claim reimbursement for controlled drugs and specific non-controlled drugs (e.g., muscle relaxants, etc.) to cover only those prescriptions written by a beneficiary’s designated provider(s).

3.1.4 The TPharm contractor shall send letters in accordance to paragraph 3.4.

3.1.5 The contractor and TPharm contractor shall develop a process to communicate the notifications and beneficiary determinations.

3.2 Restriction Types

3.2.1 Default restriction: the TPharm contractor shall adjudicate claims for all Drug Enforcement Agency (DEA) Schedule II-V medications only if prescribed by the beneficiary’s selected prescriber.

3.2.2 Selected medication restriction: if specified by the contractor, the TPharm contractor shall adjudicate claims for selected classes of or specific medications only if prescribed by the beneficiary’s selected prescriber.

3.2.3 All medications restrictions: if specified by the contractor or beneficiary, the TPharm contractor shall adjudicate claims for all medications only if prescribed by the beneficiary’s selected prescriber.

3.2.4 Pharmacy restriction: if specified by the contractor or beneficiary, the TPharm contractor shall only adjudicate (or accept) claims for all medications from specified pharmacy(ies) and denied from other pharmacies and other points of service.

3.2.4.1 This may include specific Market/MTF pharmacy(ies); however due to limited formulary availability, the Market/MTF may need to request an override for drugs not carried at the Market/MTF pharmacy.

3.2.4.2 The TPharm contractor shall use the pharmacy restriction in conjunction with the beneficiary’s selected prescriber, if requested by the beneficiary or contractor.

3.3 TPharm Contractor’s Systems

3.3.1 The TPharm contractor’s system shall have adjudication edits in place to prevent multiple fills with overlapping days’ supply at the same or multiple pharmacies; therefore, pharmacy restrictions are not necessary but may be added when appropriate.

3.3.2 The TPharm contractor’s system shall be able to include other drugs by request of the contractor, Government, provider or beneficiary. For example, when a previously unscheduled drug is under review for categorization of scheduling, the Government may request it to be added to the list during the interim between the DEA’s Notice of intent to schedule and the effective date of scheduling.

3.4 Beneficiary Notification

3.4.1 The TPharm contractor shall, upon notification of the beneficiary’s restriction status, send a letter to the beneficiary explaining the program and medical review results.

3.4.1.1 The TPharm contractor shall ask the beneficiary to select:

3.4.1.1.1 A single provider for pain management; and

3.4.1.1.2 A primary emergency department.

3.4.1.2 Additional providers may be added by beneficiary request and Government concurrence.

3.4.1.3 The TPharm contractor shall, at a minimum:

3.4.1.3.1 Give the beneficiary 14 calendar days from the date the notification letter is sent to respond with their selected options;

3.4.1.3.2 Notify the beneficiary in the initial letter if the beneficiary does not respond within the 14 calendar days or chooses not to participate that the contractor and TPharm contractor shall place the beneficiary in 100% prepay status and the beneficiary will be responsible for the costs of medical services and pharmaceuticals until selections have been provided;

3.4.1.3.3 Shall provide an email address and phone number in the initial letter for beneficiary support;

3.4.1.3.4 Shall accept the beneficiary’s selection response in writing (fax, email, or letter) or by phone at the designated phone number provided in the notification letter; and

3.4.1.3.5 Inform the beneficiary has 90 calendar days to request an initial re-review by the contractor.

3.4.2 The TPharm contractor shall send a notification letter to all individual commercial providers that prescribed to the beneficiary in the past 180 calendar days.

3.4.2.1 The TPharm contractor shall not send letters to individual Market/MTF providers.

3.4.2.2 The TPharm contractor shall include in the letter, at a minimum:

3.4.2.2.1 An explanation of the concern of over utilization;

3.4.2.2.2 A request for confirmation of prescribing; and

3.4.2.2.3 Notification of future restrictions.

3.4.3 The TPharm contractor shall provide the appropriate contractor with jurisdiction to oversee compliance with the beneficiary’s choice of provider(s) and emergency department within three business days of receiving the beneficiary’s selection notification.

3.4.4 Once the beneficiary has made the appropriate selections, the beneficiary may request a re-review for previously pended or denied claims. The beneficiary may also request a list of all pended or denied claims. The beneficiary requests are not required to be in writing.

3.4.4.1 The contractor shall, at a minimum:

3.4.4.1.1 Note the date requested and complete the review(s) in 30 calendar days; and

3.4.4.1.2 Forward the request for re-review to other participating contractor(s) within 24 hours to fulfill the request.

3.4.4.2 The TPharm contractor shall, at a minimum:

3.4.4.2.1 Review previous claims that were subject to the 100% copay; and

3.4.4.2.2 Re-process claims that meet the beneficiary’s selection and refund the beneficiary in accordance to paper claims standards; or

3.4.4.2.3 Deny claims that do not meet the beneficiary’s selection and notify the beneficiary of their appeal rights.

3.4.5 While restricted, the beneficiary may need to request overrides due to emergent need (illness while traveling) or changing circumstances (moved, provider retired, etc.). The beneficiary may request a temporary override (emergent need) or permanent change.

3.4.5.1 The TPharm contractor shall provide an email address and phone number on its website, in addition to the initial notification letter, to support those needs.

3.4.5.2 The TPharm contractor shall send the information to the originating contractor for authorization to override, if the beneficiary requests more than two overrides/changes during a six month period.

3.5 Requests to remove a beneficiary from restrictions:

3.5.1 A case manager, physician, or other provider may make the request based upon a change in clinical condition.

3.5.1.1 The originating contractor shall review this request for concurrence.

3.5.1.2 The originating contractor shall respond in seven calendar days by notifying the requestor of the results.

3.5.1.3 The TPharm contractor shall, if it receives the request, forward the request within 24 hours of receipt to the originating contractor for resolution.

3.5.2 The TPharm contractor shall monitor the Morphine Equivalent Dose (MED) for opioid based restrictions.

3.5.2.1 The TPharm contractor shall, when it detects that the MED has dropped below 30mg for 180 consecutive days, notify the originating contractor and the beneficiary shall be removed from the program in 30 calendar days unless the contractor indicates otherwise.

3.5.2.2 The originating contractor may request to maintain the restriction.

3.5.3 The contractor shall provide written notification to beneficiary of the results.

3.5.3.1 If the result is removal from the program, the letter shall identify the date of removal.

3.5.3.2 If the result is the not to remove, the letter shall identify the next date a review can be requested.

3.5.4 The contractor shall provide a courtesy copy of the result to the Government’s TPharm point(s) of contact.

4.0 RE-REVIEWS TIMELINES

4.1 The contractor shall offer each beneficiary an opportunity to request a re-review of the initial decision to restrict the beneficiary. The contract shall also, at a minimum:

4.1.1 Inform the beneficiary that his or her attending provider(s) may discuss the case with the reviewer.

4.1.2 Provide the beneficiary 90 calendar days from the date of the original notification letter (paragraph 3.4.1) to request an initial re-review;

4.1.3 Respond to the beneficiary’s request within 30 calendar days for a re-review.

4.1.3.1 If there is no initial request for a re-review, the procedures in paragraph 4.2 are applicable.

4.1.3.2 Being placed on the PMP restriction program is not appealable but claims denied due to restrictions in place shall be appealable as described in paragraph 3.4.4.

4.2 The beneficiary may request an annual review or anytime they have documentation from their provider about a clinical condition which substantiates utilization.

4.2.1 The TPharm contractor, if it receives the request, shall forward the request within 24 hours to the appropriate contractor for medical review.

4.2.2 The contractor shall respond to the beneficiary within 30 calendar days on annual reviews.

4.3 As appropriate, the requirement for 100% prepayment review or restrictions may be removed in the face of new or updated information about the beneficiaries’ clinical condition.

4.4 The TPharm contractor shall, if a beneficiary needs assistance with Market/MTF based restrictions, facilitate a resolution with the appropriate Market/MTF site.

4.5 The Market/MTF has final say whether they will re-review the case. Requirements in paragraph 4.1 do not apply to the Market/MTF.

5.0 REPORTS

5.1 Monitoring Reports

5.1.1 The TPharm contractor shall provide to the Government a quarterly activity report on individuals currently restricted which includes date restricted, restrictions in place, source of restriction, and any other notes necessary for monitoring compliance (number of emergent override request, compliance with restrictions, etc.). For reporting details refer to DD Form 1423, CDRL, located in Section J of the applicable contract.

5.1.1.1 The data shall be arranged in a tiered report, to include but not limited to:

5.1.1.1.1 Summary of individuals included for the quarter;

5.1.1.1.2 Claim level detail for the past 180 calendar day of the individuals included for the quarter;

5.1.1.1.3 Identify how many times within the past five years the individuals have been identified on the report; and

5.1.1.1.4 Latest status reported by the contractor or Market/MTF.

5.1.2 The TPharm contractor shall provide a copy of this report to the respective contractor and Market/MTF based upon the beneficiary’s Primary Care Manager (PCM) assignment.

5.2 Summary Reports

5.2.1 The contractor (excluding Markets/MTFs) shall provide to the Government an annual summary status report of all beneficiaries currently in the restriction program and summary of the case history to include summary of the clinical review, the support services being provided, beneficiary restrictions, and beneficiary compliance. For reporting details refer to DD Form 1423, CDRL, located in Section J of the applicable contract.)

5.2.2 The TPharm contractor shall provide to the Government office a monthly list of beneficiaries to whom restrictions have been applied in their area. For reporting details refer to DD Form 1423, CDRL, located in Section J of the applicable contract.

5.2.3 The TPharm contractor shall provide a courtesy copy of this report to the respective contractor and Market/MTF.

5.2.4 The TPharm contractor shall provide to the Government a monthly summary report of Market/MTF prescribers that write for restricted beneficiaries that are not assigned to them or Market/MTF prescribers writing a high volume of Schedule II-V prescriptions. The TPharm contractor shall provide summary statistics for Market/MTF pharmacies that bypass restriction requirements and dispense a prescription. For reporting details refer to DD Form 1423, CDRL, located in Section J of the applicable contract.

5.2.5 The TPharm contractor shall provide a courtesy copy of this report to the respective Market/MTF.

5.2.6 The contractor, using physician portals, shall maintain a searchable database of patients currently on restriction in their secured website and make available to their network providers. These physician portals shall be compliant with Health Insurance Portability and Accountability Act (HIPAA) Privacy standards, HIPAA Electronic Transaction standards, and any other applicable Federal regulations.

5.2.7 The contractor shall, prior to opening the portal, provide the Government with access to the portal and validate that its portal has the appropriate access restrictions.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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