Drug overutilization review program for Medicare

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.