Policy/Procedure Number: MPRP4020 (previously RP100420) / Lead Department: Health Services
Policy/Procedure Title: : Restricted Status for Members Receiving Prescription Medications / ☒External Policy
☐Internal Policy
Original Date: 04/25/1994 / Next Review Date: 02/14/2019
Last Review Date: 02/14/2018
Applies to: / ☒ Medi-Cal / ☐ Employees
Policy/Procedure Number: MPRP4020 (previously RP100420) / Lead Department: Health Services
Policy/Procedure Title: Restricted Status for Members Receiving Prescription Medications / External Policy
Internal Policy
Original Date: 04/25/1994 / Next Review Date: 02/14/2019
Last Review Date: 02/14/2018
Applies to: / Medi-Cal / Employees
Reviewing Entities: / IQI / P & T / QUAC
OPerations / Executive / Compliance / Department
Approving Entities: / BOARD / COMPLIANCE / FINANCE / PAC
CEO / COO / Credentialing / DEPT. DIRECTOR/OFFICER
Approval Signature: Robert L. Moore, MD, MPH, MBA / Approval Date: 02/14/2018
  1. RELATED POLICIES:

CMP09 – Fraud, Waste and Abuse Reporting

  1. IMPACTED DEPTS.:
  2. Member Services
  3. Grievances and Appeals
  4. Pharmacy Department
  5. Compliance
  1. DEFINITIONS:

N/A

  1. ATTACHMENTS:
  2. Prescription Medication Case Review Form
  3. Restricted Status Member Log
  4. Provider Notification of Member Restricted Status
  5. Provider Notification of Member Removed from Restricted Status
  6. Provider Notification of Member Restricted Status Change of Pharmacy
  7. Restricted Status for Controlled Medications - PHC / Health Services Department Checklist
  8. Pharmacy Benefits Manager Notification Form
  9. Form 2 Coverage Change Request Form
  10. HS Member Status Change Request Form
  11. Member Notification of Restricted Status For Controlled Drugs and Pharmacy Restriction
  12. Member Notification of Restricted Status Pharmacy Restriction Only
  13. Member Notification of Restricted Status Removed
  14. Provider Notification Member Restriction Expiration
  15. Compliance Notification Form
  16. MC-609 Form (RAC Reporting)
  1. PURPOSE:

To describe the process for members to be placed on restricted status for receiving prescription medications.

  1. POLICY / PROCEDURE:
  2. A member of the Partnership HealthPlan of California (PHC) may be placed on restricted status for receiving medications prescribed in an outpatient setting based on a determination by the Chief Medical Officerwhen such services have been used inappropriately by the member.
  3. The Pharmacy Department shall review members whom are on restricted status annually.
  4. Members found by the Chief Medical Officer to be misusing prescription drugs may be subjected to the following types of restrictions for a period of 12 months.
  5. Prior authorization for specific medications through the PHC Pharmacy Department.
  6. Prior authorization for all controlled medications through the PHC Pharmacy Department.
  7. Restriction to one pharmacy for all controlled medications, chosen by PHC Pharmacy Department based upon the member’s most-utilized pharmacy according to their records.
  8. The member would have the option to change the pharmacy selected by PHC if he/she notifies the PHC Member Services department within 10 days of the date of the letter received from PHC, advising them of being placed on restricted status.
  9. Requests to place a member on a restricted status may be made by providers or PHC staff to the Chief Medical Officer, Health Services Director, or PHC Pharmacy staff.
  10. The imposition of a restriction on a member for prescription medications will not affect the eligibility of the person for other MediCal benefits, nor apply in any instance where an emergency exists that requires immediate treatment. In addition, the member can still obtain the restricted service provided that prior authorization was obtained by the provider.
  11. Thirty (30) days prior to the end of the member's restricted period, the Pharmacy Department will review authorizations, claims, and other documentation related to the restriction. If the member’s provider had originally agreed to restricted status for the member, then the provider will be contacted via certified mail and requested to provide input concerning the continuation or removal of restricted status. Theprovider will be requested to respond within 10 business days from the date of the certified letter. The Chief Medical Officer will review provider’s recommendations (if provided within 10 days of the date of the certified letter) and may continue the restriction of a member for an additional period of twelve (12) months. The Chief Medical Officer will make the final decision regarding the continuation or removal of restricted status.
  12. In cases of inappropriate prescribing, the Chief Medical Officer will decide if a provider should be referred for Potential Quality Issues (PQI).
  13. The following procedure will be followed when evaluating a request for restricted status:
  14. Review of report from pharmacy benefits manager on prescription usage by the member in question and review of claims/encounter data on the member's usage of specific services.
  15. Communication with the prescribing physician(s) via certified mail about the member's use of drugs and the current and/or historical usage of medications, and possible efforts by the physician(s) to monitor/manage the drug usage.
  16. Documentation to support the restriction request may include, but are not limited to, the following:
  17. Copies of medical records that support the request.
  18. Reports summarizing claims paid and/or denied for the medications in question.
  19. Other reports analyzing utilization of prescription medications.
  20. Member Services’ Complaint Log.
  21. Provider documentation via fax or phone call of the need for restricted status.
  22. The Pharmacy Director will review the request and supporting documentation for placing a member on restricted status, and if it is determined that the member should be placed on restricted status, then this recommendation will be sent to the member’s provider via Certified Mail requesting the provider’s input with placing member on restricted status (SeeAttachmentA).
  23. The provider will be requested to respond within 10 business days from the date of the certified letter.
  24. If the provider does not respond within 10 business days, then a pharmacy department representative will contact the provider’s office and request a response.
  25. Once the provider responds, all of the members’ files pertaining to potential restricted status are forwarded to the Chief Medical Officer (CMO) for review.
  26. If misuse of prescribed medication is substantiated as a possible case of Fraud, Waste and Abuse, the member’s records may be provided to the CMO for restricted status determination without advance notification to the member’s provider and PHC Compliance Officer will be notified immediately, without delay, via RAC_Reporting using the MC-609 form.
  27. The Chief Medical Officer makes the final decision for placing a member on restricted status.
  28. If the Chief Medical Officer approves the request to place a member on restricted status, the Pharmacy Department staff will add the member to the “Restricted Member” log; anda member file with copies of all supporting documentation and correspondence will be created.Files will be secured in a locked file cabinet in the Pharmacy Department. The log and member file is considered confidential and will be used by PHC to verify a member’s restricted status. (See Attachment B)
  29. The restricted member will be notified about being placed on restricted status and will be advised of the pharmacy he/she is restricted to (if applicable) via certified mail, from the Chief Medical Officer.
  30. The restricted member will have 10 days from the date of the certified letter to contact Member Services if they wish to change the pharmacy he/she will be restricted to using for all controlled medication prescriptions.
  31. The member can change the pharmacy that they are assigned to using, no more frequently than once every 30 days, unless approved by PHC.
  32. The member can use any pharmacy they chose for all other prescribed medications.
  33. The Pharmacy Department staff will notify the following when a member is initially placed on restricted status; has been reviewed and will continue on restricted status; has been removed from restricted status, or restricted status has been changed.
  34. The member's PCP and/or other prescribers. (See Attachments C, C1, C2, F)
  35. The member's pharmacy. (See Attachments C, C1, C2)
  36. The pharmacy benefits manager, who will place an edit into the pharmacy computer system if the member is placed on restricted status. (See Attachments D, D1, D1a)
  37. The Member Services Department, whowill place a code into the PHC system if the member is placed on restricted status. (See Attachments D and D2)
  38. The provider who initiated the request for restricted status. (See Attachments C, C1, C2, F)
  39. The member, by a letter stating that such a restriction has been placed on them, or removed, and informing them that they have the right to file a grievance or request a state fair hearing. (See Attachments E, E1 and E2)
  40. PHC Compliance Officer, who will be notified via email by the Pharmacy Director or his/her representative via .
  1. REFERENCES:

N/A

  1. DISTRIBUTION:
  2. PHC Department Directors,
  3. PHC Provider Manual
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:

Pharmacy Services Director

  1. REVISION DATES:

Medi-Cal

06/06/95; 10/10/97 (name change only); 07/21/99; 08/15/01; 09/18/02; 05/19/04, 08/18/11; 01/17/13; 10/1/15; 04/06/17, *02/14/18

*Through 2017, Approval Date reflective of the Pharmacy & Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO:

Healthy Families:

MPRP4020 - 08/18/2011 to 03/01/2013

Healthy Kids

08/18/2011; 01/17/13; 10/1/15 to 12/01/16 (Healthy Kids program ended12/01/2016)

XI. POLICY DISCLAIMER:

A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

1. Consistent with sound clinical principles and processes;

2. Evaluated and updated at least annually;

3. If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request.

B. The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

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