June 28, 2013 07:57 ET

NCPDP White Paper Tackles Overutilization of Opioids, Addresses Gap to Reduce Fraud and Abuse for Medicare Part D Plans

White Paper Details Standardized Method for Plan Sponsors to Share Information Related to Overutilization of Opioids as Beneficiaries Change Health Plans

SCOTTSDALE, AZ--(Marketwired - Jun 28, 2013) - The National Council for Prescription Drug Programs (NCPDP) today announced the availability of a white paper that closes a gap for fraud and abuse, defining a process that payers offering Medicare Part D plans can use to communicate information about overutilization of opioids when beneficiaries switch health insurance plans. The white paper provides industry best practice guidance to help payers systematically address and proactively identify beneficiaries who are known to be using opioids inappropriately.

Centers for Medicare & Medicaid Services (CMS) guidance related to addressing opioid overutilization in the Medicare Part D population was initially released in 2011 following a U.S. Government Accountability Office (GAO) report that revealed approximately 170,000 beneficiaries had acquired frequently abused drugs such as hydrocodone and oxycodone at a total cost of $148 million. The CMS 2013 Call Letter described the need for effective concurrent and retrospective drug utilization review (DUR) programs, compliance with drug utilization management (DUM) requirements, and reducing fraud and abuse.

"Misuse and overuse of opioids is a national epidemic and our white paper gives health plans industry guidance on critical first steps in managing it," said Lee Ann Stember, president of NCPDP. "We look forward to continuing our work with all healthcare stakeholders to develop industry-wide consensus-based solutions for combating opioid abuse, protecting patients, and reducing fraud, waste and abuse."

When a Part D beneficiary changes insurers, CMS requires that the plan he or she dropped offer to submit information to that beneficiary's new insurer. NCPDP's white paper, "NCPDP Recommendations for a Standardized Process to Share Medicare Part D Opioid Overutilization Data Between Sponsors," details a three-step process health plans can use to initiate, conduct and standardize the required transaction over secure e-mail. The new plan has two weeks to communicate its acceptance or rejection from the previous health plan. If the new plan accepts the offer, the old plan should provide the information and supporting documentation within two weeks of the acceptance date. In the absence of a response within the two week time period, the previous plan is instructed to treat it as a rejection of its offer.

NCPDP intends to further refine the process and automate it in the future.
The NCPDP white paper can be accessed at

To access NCPDP's webinar on "Medicare Part D Opioid Overutilization Data Sharing Between Sponsors," visit

Founded in 1977, NCPDP is a not-for-profit, ANSI-accredited, Standards Development Organization with over 1,600 members representing virtually every sector of the pharmacy services industry. Our diverse membership provides leadership and healthcare business solutions through education and standards, created using the consensus building process. NCPDP has been named in federal legislation, including HIPAA, MMA, and HITECH. NCPDP members have created standards such as the Telecommunication Standard and Batch Standard, the SCRIPT Standard for e-Prescribing, the Manufacturers Rebate Standard and more to improve communication within the pharmacy industry. Our data products include dataQ®, a robust database of information on more than 76,000 pharmacies, and HCIdea®, a database of continually updated information on more than 2.3 million prescribers. NCPDP's RxReconn® is a legislative tracking product for real-time monitoring of pharmacy-related state and national legislative and regulatory activity. For more information about NCPDP Standards, Data Services, Products, Educational Programs and Work Group meetings, go online at or call (480) 477-1000.

Contact Information

    Janet Cabibbo
    Amendola Communications for NCPDP
    480-664-8412 ext. 15
    Email Contact