Drug overutilization review program for Medicare

The Centers for Medicare & Medicaid Services (CMS) has developed an overutilization monitoring system. This system helps ensure plans are implementing effective and appropriate controls against opioid and APAP (acetaminophen, brand name Tylenol) overutilization. Additionally, the system facilitates the review of beneficiaries referred by the CMS 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 equivalent average daily dose over the last six months.
  • Medication purchased at two or more different pharmacies.
  • Medications prescribed by two or more different doctors.
  • Patients who haven't used opioids in the previous 180 days are limited to a seven-day opioid supply.