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Prescription Monitoring Program (PMP)

The PMP is designed to identify potential unsafe behavior with regard to controlled medications and prevent or decrease the risk of overutilization by restriction implementation. Beneficiary enrollment can be requested by the Military Treatment Facility or the TRICARE Managed Care Support Contractor.

Identification

Express Scripts (ESI) identifies candidates for enrollment based on pre-determined criteria, including utilization patterns of controlled substances and/or other high risk medications. Identified beneficiaries are sent to the respective TRICARE Managed Care Support Contractor or the assigned Military Treatment Facility to review prescription history in conjunction with medical history to determine enrollment. Identification can also occur internally by the TRICARE Managed Care Support Contractor or Military Treatment Facility.

MTF Restriction Program

Restriction Requests
Providers, Nurse Case Managers, and/or Pharmacists can enroll identified patients into the Prescription Monitoring Program by submitting the MTF Restriction Request form (below) to ESI.

The requestor, or point of contact, designates the restriction type and authorized provider(s). All medications, controlled medications, or specified medications can be restricted to a provider or list of providers and/or a pharmacy or list of pharmacies.

Restriction Modifications
The point of contact submits the restriction request form, indicating a modification is needed and includes the updated provider and/or pharmacy information. Restriction override and removal forms can be requested through the Express Scripts, Prescription Monitoring Department.

Restriction request forms should be submitted via fax or if unavailable, CAC encryption submission options are available.

ESI facilitates the restriction as requested. The point of contact manages the restriction and must notify ESI if updates are needed.

System Messaging
Prescriptions outside of the restriction requirements will process as follows:

CHCS
ESI will return an override-able lock-in edit to the MTF pharmacy processing the claim:
M2 RECIPIENT LOCKED-IN. HAVE BENEFICIARY CALL 800-332-5455x 340567

MHS Genesis /Retail/ Mail Order
The prescription will reject with an M2 and additional messaging dependent on the reject reason:
M2 PHARMACY RESTRICTION
M2 PHARMACY/PHYSICIAN RESTRICTION
M2 PHYSICIAN RESTRICTION

*MTFs transitioning from CHCS to MHS Genesis will experience hard rejects for PMP enrolled patients filling outside of restriction requirements. Claim level overrides will be available but additional steps will be required. Prior to implementation, training will be provided to sites undergoing this transition.

Reporting
MTF Providers, Nurse Case Managers, and/or Pharmacists can request access to Prescription Monitoring Reporting for their site by emailing the ESI Prescription Monitoring Department: TRICARE111@express-scripts.com.

Monthly MTF Prescription Monitoring Report (M290)
Monthly Restriction Activity
  • Program to Date Restriction Details
  • Non-Restricted Candidates – Beneficiaries identified as possible candidates
  • Non-Compliant Beneficiaries – Beneficiaries attempting to fill outside of lock in criteria
  • MTF Prescriber Summary – Prescribers writing for restricted beneficiaries
  • MTF Prescribers – High Volumes – Prescribers writing high volumes of controlled substances
Quarterly Prescription Monitoring Program Utilizer Report (Q240)
  • Program to Date Restriction Details
  • Non-Compliant Beneficiaries – Restricted beneficiaries that attempted to fill a prescription from an unauthorized prescriber and/or pharmacy
  • Current Quarter Candidates - Beneficiaries identified based on pre-determined criteria, including utilization of controlled substances and/or other high risk medications
  • Current Pharmacy Claims – Pharmacy claims detail for identified candidates
  • Prior Candidates – Previously identified candidates

Managed Care Support Contractor Restriction Program

Restriction Requests
The TRICARE Managed Care Support Contractor requests enrollment through the Express Scripts, Prescription Monitoring Department. ESI sends an initial letter to the identified enrollee, explaining the requirements of the program and requests the beneficiary to select one provider and one emergency room to obtain controlled medications.

Restriction Modifications
Provider and/or emergency room updates must be sent in writing to the Express Scripts, Prescription Monitoring Department. Requests to be removed from the Prescription Monitoring Program should be sent via email or fax and will be reviewed by the TRICARE Managed Care Support Contractor on an annual basis or if there is clinical evidence to support removal from the program.

System Messaging
Prescriptions outside of the restriction requirements will be rejected.

Retail/ Mail Order
A prescription will reject with an M2 and additional messaging dependent on the reject reason:
M2 PHARMACY RESTRICTION
M2 PHARMACY/PHYSICIAN RESTRICTION
M2 PHYSICIAN RESTRICTION

Reporting
Monthly Prescription Monitoring Program Region Report (M280)
  • Monthly Restriction Activity
  • Program to Date Restriction Details
  • Non-Restricted Candidates – Beneficiaries identified as possible candidates
  • Non-Compliant Beneficiaries – Beneficiaries attempting to fill outside of lock in criteria
Quarterly Prescription Monitoring Program Utilizer Report (Q240)
  • Program to Date Restriction Details
  • Non-Compliant Beneficiaries – Restricted beneficiaries that attempted to fill a prescription from an unauthorized prescriber and/or pharmacy
  • Current Quarter Candidates - Beneficiaries identified based on pre-determined criteria, including utilization of controlled substances and/or other high risk medications
  • Current Pharmacy Claims – Pharmacy claims detail for identified candidates
  • Prior Candidates – Previously identified candidates

Prescription Monitoring Program Contact Information
Email: TRICARE111@express-scripts.com
Phone: 866-333-1348
Fax: 866-579-4662
Mail: Express Scripts, Inc.
Prescription Monitoring Department
1 Express Way
St. Louis, MO 63121
Mail Route HQ1-3N03


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