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 member services at 1-877-232-7566 (TTY: 711)

Not a member? Talk with a sales representative at 1-877-234-0126 (TTY: 711), including for alternate formats and languages.

Mailing Address:

Prevea360 Medicare Advantage
PO Box 56099
Madison, WI 53705

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H9096_prevea360.com
Updated: 1/3/2022