Medicare Drug Management Program

Medicare Drug Management Program

We have a program that helps make sure members safely use prescription opioids and other frequently abused medications. This program is called a Drug Management Program (DMP). If you use opioid medications that you get from several doctors or pharmacies, or if you had a recent opioid overdose, we may talk to your doctors to make sure your use of opioid medications is appropriate and medically necessary. Working with your doctors, if we decide your use of prescription opioid or benzodiazepine medications is not safe, we may limit how you can get those medications. If we place you in our DMP, the limitations may be:

  • Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain pharmacy(ies)

  • Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain doctor(s)

  • Limiting the amount of opioid or benzodiazepine medications we will cover for you

If we plan on limiting how you may get these medications or how much you can get, we will send you a letter in advance. The letter will explain the limitations we think should apply to you. You will have an opportunity to tell us which doctors or pharmacies you prefer to use, and about any other information you think is important for us to know. After you’ve had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming the limitation. If you think we made a mistake or you disagree with our determination or with the limitation, you and your prescriber have the right to appeal. If you appeal, we will review your case and give you a decision. If we continue to deny any part of your request related to the limitations that apply to your access to medications, we will automatically send your case to an independent reviewer outside of our plan. See Chapter 9 in your Evidence of Coverage for information about how to ask for an appeal.

You will not be placed in our DMP if you have certain medical conditions, such as active cancer related pain or sickle cell disease, you are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility. If you have further questions please contact the Pharmacy Customer Care Center.