Drug overutilization review program for Medicare

The Centers for Medicare & Medicaid Services (CMS) has developed an overutilization monitoring system to ensure that plans are implementing effective and appropriate controls against opioid and APAP (acetaminophen, brand name Tylenol®) overutilization and for review of beneficiaries referred by the CMS Center for Program Integrity (CPI) for possible overutilization issues.

The goal of overutilization monitoring is to prevent:

  • Overuse of APAP: More than the FDA daily maximum APAP dose of 4 grams
  • Overuse of opioids: More than a 90 mg morphine equivalents average daily dose over the last six months
  • Limited to a seven-day supply of opoids if they haven't used opoids in the last 108 days.. 

Questions? Contact us.

Senior man using phone and laptop in his living room.Members
Talk with our Customer Care Center at 1-877-301-3326 (TTY:711).
Not a member?
Talk with a WellFirst Health Medicare sales rep at 1-833-551-0565. You can also call to ask for information in alternate formats and languages. 

Mailing address

WellFirst Health Medicare Advantage
PO Box 56099
Madison, WI 53705-9399
View our Medicare disclaimers

Updated 10/1/20