Prescription Drug Monitoring Program (PDMP)

How this system supports the Medicaid Program

PDMP systems monitor the use of controlled substances, including prescription drug history, prescription drug usage, and demographic information of prescribing providers.

CMS-Required Outcomes

Each CMS-Required outcome is based on statutory or regulatory requirements. CMS-Required Outcomes and Metrics are used to demonstrate that a system is compliant with the applicable federal regulations which pertain to that specific system or module. CMS-Required outcomes form the baseline for system/module functionality, which must continue to receive enhanced federal funding for operations.

Click here to download the CMS-Required outcomes in a CSV file

Reference #	CMS Required Outcomes	Default Metrics	Regulatory Sources
PDMP 1 Qualified PDMP	Covered providers have near real-time access to: a. Information regarding Medicaid beneficiary’s prescription drug history. b. The number and type of controlled substances prescribed to and filled for the covered individual during at least the most recent 12-month period. c. The name, location, and contact information (or other identifying number selected by the state, such as a national provider identifier issued by the CMS National Plan and Provider Enumeration System) of each covered provider who prescribed a controlled substance to the covered individual during at least the most recent 12-month period.	- Real-time access: Average time (in mins) to access a report on bene prescription drug history	Section 1944(b) of the Act Section 5042 – Medicaid PARTNERSHIP Act CMS FAQs-SUPPORT for Patients and Communities Act
PDMP 2 Workflow Integration	Providers can easily use the PDMP information through workflow integration, which may include electronic prescribing system for controlled substances.	---	Section 1944(b) of the Act Section 5042 – Medicaid PARTNERSHIP Act CMS FAQs-SUPPORT for Patients and Communities Act
PDMP 3 Data-sharing Agreements	The state has data-sharing agreements with all contiguous states to track patients, prescribers, and prescriptions across state lines.	- Provide copies of data-sharing agreements entered with contiguous states	Section 1944(b) of the Act Section 5042 – Medicaid PARTNERSHIP Act CMS FAQs-SUPPORT for Patients and Communities Act
PDMP 4 Medicaid Program Access to PDMP (if applicable)	The state medical and pharmacy directors and any designee has access to the PDMP information in an electronic format based on data-sharing agreements in place (subject to state law).	- Provide a copy of the report of issues reported for designated users who could not or were denied access	Section 1944(b) of the Act Section 5042 – Medicaid PARTNERSHIP Act CMS FAQs-SUPPORT for Patients and Communities Act
PDMP 5 Required Reporting	The state produces data for the reports that are required to be submitted in the Annual Report to HHS.	- Quantity of daily morphine milligram equivalents prescribed for controlled substances. - the number and Quantity of daily morphine milligram equivalents prescribed for controlled substances per covered individual. - number of occurrences of data or privacy breaches of a qualified PDMP that includes the number of covered individuals impacted by each breach.	Section 1944(e) of the Act Section 5042 – Medicaid PARTNERSHIP Act 42 CFR 433.112(b)(15) CMS FAQs-SUPPORT for Patients and Communities Act
PDMP 6 Utilization and Quality Reports	The system produces reports to contribute to reports to HHS by the State Drug Utilization Review (DUR) Board and for program evaluation, continuous improvement in business operations, transparency and accountability, as well as identify patterns of fraud, abuse, gross overuse, excessive utilization related to limitations identified by the state, inappropriate or medically unnecessary care, or prescribing or billing practices that indicate abuse or excessive utilization among Medicaid physicians, pharmacists and enrollees associated with specific drugs or groups of drugs.	- Number of covered individuals concurrently prescribed opioids and benzodiazepines. - List of covered individuals who were prescribed opioids from multiple providers. - number and/or percentage of opioid-related hospitalizations, ER visits, urgent care visits for covered individuals.	Section 1944 (e)(1) of the Act Section 1927(g)(2)(B) and (g)(3)(D) of the Act Section 1004 of the SUPPORT Act 42 CFR 433.112(b)(15) CMS FAQs-SUPPORT for Patients and Communities Act Centers for Disease Control

State-Specific Outcomes - CMS Approved

States requesting enhanced FFP for systems that fulfill state-specific program needs, beyond minimum legal requirements and the baseline of the CMS-required outcomes, should propose State-Specific Outcomes which address the proposed enhancements.

When drafting state-specific outcomes statements, keep these tips in mind.

Examples for Prescription Drug Monitoring Programs

We are actively gathering and evaluating outcomes statements crafted by states for this business area.

Please send examples from your state that you’d like to share to MESCertificationRepo@cms.hhs.gov. Our team will collect and share the best examples.

Click here to download the State-Specific outcomes in a CSV file

State	Medicaid Program Goal	Outcome Statement	Metric(s)