Fact sheets for Colorado, Massachusetts, New York, Utah, and Washington were revised on September 27, 2016 to reflect updated information from select states regarding patient exclusions, beneficiary notifications, the appeals process, and drugs managed through the PRR.
Public and private insurance plans use patient review and restriction (PRR) programs to encourage the safe use of opioids and other controlled substances. Through PRRs, insurers assign patients who are at risk for substance use disorder (SUD) to predesignated pharmacies and prescribers to obtain these drugs.
These fact sheets present key features of states’ Medicaid fee-for-service (FFS) PRR programs, acquired from a 2015 survey and literature review by The Pew Charitable Trusts. The nationwide survey captured information on program characteristics, structures, and trends. Of the 41 states that responded (plus the District of Columbia and Puerto Rico), 38 operate an FFS PRR.