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 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.
• Limited to a seven-day supply of opioids if they haven't used opioids in the last 108 days.