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.. 

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WellFirst Health Medicare Advantage
PO Box 56099
Madison, WI 53705-9399
 
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Updated 10/1/20