Capital Rx’s Drug Management Program (DMP) is a case management program for Medicare health plan members at-risk for misuse or abuse of frequently abused drugs (FADs), including opioids for pain management and benzodiazepines, which are often prescribed for anxiety or insomnia. Unfortunately, in the U.S., there are thousands of opioid- and benzo-related deaths every year, and abuse of these highly addictive drugs has become more frequent, even among seniors.1, 2, 3 A DMP helps create better and, ideally, more predictable outcomes for health plan members by proactively managing the cases in ways that lower the risks associated with these drugs.
To understand how DMP works and the potential value-add for payors, I spoke with Nash Albadarin, PharmD, MBA, Senior Clinical Programs Manager here at Capital Rx, and Bonnie Hui-Callahan, PharmD, CDCES, Director of Clinical Programs. We covered the basics of DMP, how Capital Rx’s program is built and works, as well as how DMP is integrated with JUDI®, our proprietary claims adjudication platform for Medicare, Medicaid, and commercial plans. The following Q&A summarizes their responses to some key questions.
What was the genesis of the DMP?
The 2019 Part D DMP Policy Guidance Memo issued by the Centers for Medicare and Medicaid Services (CMS) requires Medicare Part D sponsors to have a DMP. This was in response to the opioid crisis and for plan years beginning on or after January 1, 2022. While DMP is a relatively new requirement, it’s worth noting that some health plans had DMPs before 2022, and medication management programs have been around for decades. For more detail on the requirements, interested readers should check out the CMS page on Improving Drug Utilization Review Controls in Part D.
It seems like DMP is a very structured Medicare program – i.e., the process is specific. How does it work?
It is a standardized CMS program with a defined process that everyone follows. At Capital Rx, our CMS-compliant program consists of the following components, which JUDI enhances
- Member Identification: Identify potential at-risk beneficiaries (PARBs) for case management via Capital Rx identification logic or by uploading CMS’ quarterly Acumen Files*. Cases can also be created manually in JUDI’s DMP Tool, which could be necessary if a member transfers into the plan midyear or the plan identifies members using their own targeting criteria or medical data.
- Clinical Review: Capital Rx pharmacists review member’s claims history and perform a clinical case review to ensure the minimum or supplemental DMP criteria are met and evaluate if the member should be excluded from DMP if they meet one of the program exclusions such as an individual having cancer or is in hospice or long-term care.
- Prescriber Outreach: Capital Rx pharmacists conduct multiple outreaches to the member’s opioid or benzodiazepine prescriber(s) to gather information on whether the member is or is not at risk for opioid overutilization and obtain any relevant information related to the member’s opioid utilization to ensure safe prescribing and use.
- Lock-in decision: Capital Rx pharmacists review all the member health information and case details with the Medical Director to determine if a lock-in or coverage limitation is appropriate based on a thorough clinical review.
- Member and Provider Notification of Lock-in: If a lock-in is recommended, Capital Rx notifies the member and their prescriber(s) and pharmacy(ies) about the lock-in.
- Implement Coverage Limitations: Lock-in coverage limitations are seamlessly implemented through full integration with JUDI® and can be set up to limit a member to a specific pharmacy, prescriber, and/or drug level.
- Quarterly CMS reporting: CMS-required OMS - Overutilization Monitoring System - Response Forms (ORF) and Sponsor Response Forms (SRF) are generated quarterly and populated with the appropriate codes based on case status.
Okay, can you describe the role JUDI plays a little further?
From a practical perspective, JUDI’s DMP Tool serves as a one-stop shop for managing and documenting everything related to a member’s DMP case. Our clinicians are very involved in clinical case reviews and evaluating whether members are taking FADs appropriately and not misusing or abusing them. They utilize JUDI to:
- Run identification to identify PARBs by applying the Minimum or Supplemental OMS criteria.
- Monitor member medication safety and usage through Opioid Oral Morphine Milligram Equivalent (MME) data.
- Generate automated OMS correspondence to members, prescribers, and pharmacies.
- Document, implement, and track Pharmacy and/or Prescriber drug lock-ins.
- Automatically populate quarterly ORF and SRF reports for CMS-required reporting.
It’s a fully delegated end-to-end DMP solution, including the case management by Capital Rx clinicians, ensuring members are correctly identified, outreach to prescribers/pharmacies is sent, responses are received, and lock-ins are effectuated. Also, plan sponsors can review and approve lock-ins before implementing them.
And what are the key features and benefits of using JUDI’s DMP Tool for Capital Rx’s DMP Program?
The DMP tool in JUDI enables our Capital Rx pharmacists to conduct case management and lock-ins in an organized, documented, and efficient manner. Select the drug, pharmacy, and/or prescriber to lock the member into, add the start and end dates, and it's reflected at the pharmacy in real time. The CMS reporting is fully automated, too. You click a button to generate a file that you can submit to CMS in the exact file format that CMS expects.
Like how we leverage JUDI for full-service PBM clients, the efficiencies gained by using modern technology allow us to reallocate resources to higher-value support or services.
For example, we continually monitor CMS guidelines and make updates to the JUDI DMP Tool to ensure the program is in full compliance with CMS. We also are equipped to provide audit support to plan sponsors.
Could the DMP Tool be useful to Employers or other Plan Sponsors?
Plan sponsors have dealt with rising pharmacy spend for years. Many payers have endured double-digit percentage annual increases or a high-cost claimant breaching the stop loss level. And patients with addiction issues tend to be higher-cost claimants. While DMP is presently designed for Medicare Part D plans, it could be useful for other payers, including employers, unions, municipalities, and health systems. With JUDI’s DMP Tool and Capital Rx’s unique client service model, we can help plan sponsors establish processes and identify and avoid risks that plague so much of our country. It’s the combination of technology and service that truly helps control costs, manage a pharmacy program more effectively, and keep Americans safe.
2 Maust DT, Lin LA, Blow FC. Benzodiazepine Use and Misuse Among Adults in the United States. Psychiatr Serv. 2019 Feb 1;70(2):97-106. doi: 10.1176/appi.ps.201800321. Epub 2018 Dec 17. PMID: 30554562; PMCID: PMC6358464.
3 Kramarow EA, Tejada-Vera B. Drug overdose deaths in adults aged 65 and over: United States, 2000–2020. NCHS Data Brief, no 455. Hyattsville, MD: National Center for Health Statistics. 2022. DOI: https://dx.doi.org/10.15620/cdc:121828.
*Acumen File - Quarterly Overutilization Monitoring System (OMS) identification reports released by CMS via Acumen. Please note that CMS sends its reports directly to health plans.