Drug overutilization review program for Medicare

grandpa at a park with his grandchildren

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 equivalent average daily dose over the last six months.
    • Medication purchased at three or more different pharmacies.
    • Medications prescribed by three or more different doctors.
  • Limited to a seven-day supply of opioids if they haven't used opioids in the last 108 days.

Questions?

Members
Speak with Dean Advantage Customer Care Center at 1-877-232-7566 (TTY: 711).

Not a Member?
Speak with a Dean Medicare sales representative by calling 1-877-234-0126 (TTY: 711), including for alternate formats and languages.

Mailing Address
Dean Health Plan
PO Box 56099
Madison, WI 53705

couple with a tablet

Take Me To