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Prescription Monitoring Program to Include Review of Provider Prescribing Practices

Monday, August 3, 2020

TRICARE's Prescription Monitoring Program (PMP) helps identify patients who may need assistance due to a higher use of controlled substances. Effective Aug. 3, 2020, the Defense Health Agency (DHA) is expanding this program to include a review of prescribing providers, to help identify and prevent unnecessary prescribing or over-prescribing of controlled substances, such as opioids. Under the revised PMP, Express Scripts, Inc., DHA and regional TRICARE contractors will coordinate a quarterly review of beneficiaries who were prescribed controlled substances and of the providers who prescribed them, and perform education and outreach as appropriate.  

Each quarter:

  • DHA will provide Health Net Federal Services, LLC (HNFS) a list of West Region providers who have prescribed controlled substances, such as opioids. Our medical directors will review prescribing practices based upon industry best practices and clinical practice guidelines. Providers who fall outside of what are considered to be normal prescribing patterns may be contacted by HNFS. At a minimum, HNFS’ provider outreach will include information on:
    • additional education opportunities and resources;
    • other covered TRICARE benefits that may complement treatment, such as substance use disorder and mental health treatment, alternative pain-related treatments, and supportive clinical programs; and
    • training opportunities, such as national and state Prescription Drug Monitoring Programs (PDMP) and Substance Abuse and Mental Health Services Administration (SAMHSA) training.
  • Express Scripts will continue to provide HNFS a list of TRICARE West Region beneficiaries identified with a high use of controlled substances, such as opioids. HNFS will review identified cases to determine if there is a need for a support plan, such as case or pain management, mental health services, and/or restrictions to medications. 
    • Express Scripts will send a letter to impacted beneficiaries and their prescribing providers. Beneficiaries receiving a letter must select a single provider for pain management and a primary emergency department. 
    • Beneficiaries placed in the PMP may be held responsible for 100% of pharmacy costs for all controlled medications if they do not make a provider designation or seek controlled medications from someone other than the designated provider or hospital.

Find additional information on TRICARE’s PMP at www.express-scripts.com/TRICARE.