targeted beneficiaries

(5) Medication risk management program (A) In general For purposes of this subsection, the term “medication risk management program” means a program for targeted beneficiaries that ensures that covered outpatient drugs are appropriately used to optimize therapeutic outcomes through improved medication use and to reduce the risk of adverse events. (B) Elements Such program may include the following elements: (i) The use of established principles and standards for drug utilization review and best practices to analyze prescription drug claims of targeted beneficiaries and identify outlier physicians. (ii) On an ongoing basis provide outlier physicians— (I) a comprehensive pharmacy claims history for each targeted beneficiary under their care; (II) information regarding the frequency and cost of relapses and hospitalizations of targeted beneficiaries under the physician’s care; and (III) applicable best practice guidelines and empirical references. (iii) Monitor outlier physician’s prescribing, such as failure to refill, dosage strengths, and provide incentives and information to encourage the adoption of best clinical practices. (C) Targeted beneficiaries For purposes of this paragraph, the term “targeted beneficiaries” means Medicaid eligible beneficiaries who are identified as having high prescription drug costs and medical costs, such as individuals with behavioral disorders or multiple chronic diseases who are taking multiple medications.


42 USC § 1396b(z)(5)

Scoping language

For purposes of this subsection
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