0. Advocacy Graphic


Patient Review and Restriction (PRR) Programs

Adoption Date:
April 12, 2016

Public Policy Statement on Patient Review and Restriction (PRR) Programs

Public Policy Statement on PRR Programs


Patient Review and Restriction (PRR) programs, also known as pharmacy “lock-in” programs, allow payers, including State Medicaid programs and commercial insurers, to curb a beneficiary’s overutilization, and possible misuse, of physician services and/or prescription drugs by restricting the patient to a single designated provider, pharmacy, or both. The federal regulation that authorizes the establishment of these programs within Medicaid gives broad discretion to the states to determine whether and how they are implemented:

If a Medicaid agency finds that a recipient has utilized Medicaid services at a frequency or amount that is not medically necessary, as determined in accordance with utilization guidelines established by the State, the agency may restrict that recipient for a reasonable period of time to obtain Medicaid services from designated providers only.

The only federal requirements are that Medicaid programs give patients notice and an opportunity for a hearing, ensure that restricted patients still have reasonable access to Medicaid services, and exempt emergency services from the restriction. Since the authorizing federal legislation doesn’t offer specific instructions regarding program design or the definition of excessive use of services, there is significant variation in scope and design among the programs that have been established to date.

As of May 2014, 46 state Medicaid agencies operated PRR programs. Program design varies widely between states in terms of defining high-risk controlled substance use, the scope of restrictions, and length of program enrollment. For example, states use a wide variety of criteria to determine which Medicaid beneficiaries will be enrolled in their PRR programs, from simple numeric thresholds to extensive criteria lists that include a variety of behaviors indicative of over-utilization. Most states define overutilization of controlled substances based on quantities of prescriptions filled, number of pharmacies visited, and/or number of controlled substance prescribers seen over a certain period of time. Many states use a combination of objective criteria and subjective assessment by PRR program staff to determine client enrollment. Moreover, while most Medicaid programs restrict enrollees to a single pharmacy and a single prescribing physician, others restrict only pharmacy access or tier how enrollees are restricted based on the extent of their overutilization.

PRR programs have been instituted and studied primarily in State Medicaid programs, but several commercial insurers also employ them. However, publicly available information about commercial insurer programs is scarce. Finally, while Medicare has historically been prohibited from instituting PRR programs, federal policymakers have recently proposed granting Medicare Prescription Drug Plans (PDPs) the authority to implement them. To date, PDPs have relied on the Medicare Overutilization Monitoring System (OMS), which provides plans with quarterly reports that identify patients with excessive or potentially dangerous prescription fills and primarily relies on point of sale quantity restrictions to curb medically unnecessary use.

PRR programs have been proposed as a potential tool in the effort to combat prescription drug misuse, diversion, and overdose deaths, both in state Medicaid programs and by commercial insurers. However, peer-reviewed research on the design and effectiveness of PRR programs is scarce. Studies to date, which primarily stem from publicly accessible internal Medicaid program evaluations, have demonstrated PRR programs can reduce health plan expenditures, , use of controlled substances, , or both, , but none have linked PRR programs to lower diversion rates, lower rates of substance use disorders, increased engagement in substance use disorder treatment, or reduced overdose deaths among beneficiaries. Accordingly, CDC has called for “more current and robust evaluations of PRR programs to examine impact on health-related outcomes such as hospitalizations and overdose deaths.”


In the face of scarce evidence that PRR programs are an effective mechanism to combat prescription misuse, diversion and overdose deaths, The American Society of Addiction Medicine urges extreme caution towards their use. ASAM advocates for the focus of care to be on the best outcomes for each individual patient. The implementation of a PRR program relinquishes professional judgement regarding a patient’s health in favor of a bureaucratic, one-size-fits-all approach. The potential for unintended consequences to the patient’s health is high if the circumstances of each unique patient’s clinical needs are not assessed by a trained professional. Furthermore, ASAM is concerned that third-party payers adjudicating which patients should enter PRR programs, may represent an inherently biased system, influenced primarily by financial interests such as reduced health plan expenditures.

As an alternative to PRR programs, ASAM advocates for more support of existing programs known to be effective in combating prescription misuse, diversion and overdose deaths, including increased education for prescribers on the disease of addiction and how it is treated, increased use of state Prescription Drug Monitoring Programs , improved FDA regulations and monitoring , ready access to naloxone , and increased access to treatment for addiction . Prevention and treatment are the best interventions to address the opioid epidemic. There is no substitute for the professional judgement of a caring and educated physician who has an existing therapeutic alliance with the patient.

If policymakers and payers proceed with implementing PRR programs, the American Society of Addiction Medicine strongly recommends the following:

1. Payers, including Medicaid, Medicare and commercial insurers, who choose to institute patient review and restriction (PRR) programs, design them to encourage behavior change and support recovery rather than as punitive measures.

a. A patient’s prescribing physician(s) should be alerted to the patient’s possible prescription drug misuse and encouraged to perform a comprehensive screening and/or assessment of the patient for a possible substance use disorder.

b. If indicated, the patient should be referred for follow-up treatment with a specialist pain and/or substance use disorder treatment provider.

2. More research is needed to determine the best set of criteria to use for identifying patients for enrollment.

a. A consistent, evidence-based definition of high-risk controlled substance use is needed to target patients at risk.

b. More research is also needed to determine whether these programs, and which specific elements of these programs if any, contribute to reduced incidence of substance use disorders, reductions in diversion, and reduced morbidity and mortality from substance use disorders among enrollees.

3. PRR programs should provide reasonable accommodations to patients to ensure program enrollment and de-enrollment is not overly burdensome, particularly for patients diagnosed with on-going malignant conditions, or those needing acute emergency services.

Other Considerations:

1. Payers should encourage their prescribers and pharmacists to check their state prescription drug monitoring program (PDMP) before prescribing or dispensing a controlled substance to any patient.

a. When possible, State Medicaid programs should work to integrate data between their PDMP and Medicaid claims to identify patients who may be circumventing the PRR program to obtain additional prescriptions by paying out of pocket. Such an interchange of information may help identify patients in need of substance use disorder education or referral to treatment.

2. Physicians and all other health professionals licensed to prescribe, dispense or administer prescription medications should be required to obtain training on the use of controlled substances. At a minimum, education should include:

a. The general principles of prescribing medications that are commonly associated with misuse, diversion, and addiction.

b. The recognition of addiction, assessment of the risk potential for the development of addiction, and referral to appropriate addiction treatment colleagues when addiction is identified or strongly suspected to be present.

c. How health professionals can provide education to patients about the potential harms associated with the use of controlled substances and about the safe storage of and disposal of supplies of controlled substances.

d. Guidance on how to use and interpret a prescription drug monitoring database and a urine toxicology screen.


Centers for Disease Control and Prevention.Patient Review & Restriction Programs: Lessons learned from state Medicaid programs. CDC Expert Panel Meeting Report. August 27-28, 2012. Available at: http://www.cdc.gov/drugoverdose/pdf/pdo_patient_review_meeting-a.pdf

42 CFR 431.54(e)

42 CFR 431.54(e)(1)–(3)

Roberts, A.W. and Skinner, A.C. Assessing the Present State and Potential of Medicaid Controlled Substance Lock-In Programs. J Manag Care Pharm. 2014;20(5):439-46

Tudor, CG. Medicare Part D Overutilization Monitoring System. CMS Letter to All Part D Sponsors, July 5, 2013. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/HPMS-memo-Medicare-Part-D-Overutilization-Monitoring-System-07-05-13-.pdf

Roberts, A.W. and Skinner, A.C. Assessing the Present State and Potential of Medicaid Controlled Substance Lock-In Programs. J Manag Care Pharm. 2014;20(5):439-46

Singleton TE. Missouri’s lock-in: Control of recipient misutilization. J Med Manage 1997;1:10–17.

Centers for Disease Control and Prevention. Patient Review & Restriction Programs: Lessons learned from state Medicaid programs. CDC Expert Panel Meeting Report. August 27-28, 2012. Available at: http://www.cdc.gov/drugoverdose/pdf/pdo_patient_review_meeting-a.pdf

Mitchell L. Pharmacy lock-in program promotes appropriate use of resources. Oklahoma State Medical Association Journal. August, 2009; 102(8): 276.

Tanenbaum, SJ, Dyer JL. The dynamics of prescription drug abuse and its correctives in one state Medicaid program. In: Wilford, BB (ed). Balancing the response to prescription drug abuse. Chicago: American Medical Association, 1990

Chinn FJ. Medicaid recipient lock-in program— Hawaii’s experience in six years. Hawaii Medical Journal; 44(1):9–18. January, 1985.

Blake SG. Drug expenditures: The effect of the Louisiana Medicaid lock-in on prescription drug utilization and expenditures. Drug Benefit Trends. March, 1999.

Centers for Disease Control and Prevention. Patient Review & Restriction Programs: Lessons learned from state Medicaid programs. CDC Expert Panel Meeting Report. August 27-28, 2012. Available at: http://www.cdc.gov/drugoverdose/pdf/pdo_patient_review_meeting-a.pdf

Centers for Disease Control and Prevention, Injury Prevention and Control: Prescription Drug Overdose. (2015). What States Need to Know about PDMPs. Atlanta, GA: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/drugoverdose/pdmp/states.html

American College of Physicians. Improving FDA Regulation of Prescription Drugs. Philadelphia: American College of Physicians; 2009: Policy Monograph. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)

Centers for Disease Control and Prevention. Community-Based Opioid Overdose Prevention Programs Providing Naloxone – United States, 2010. MMWR 2012;61:101-104

American Society of Addiction Medicine, Treatment Research Institute. (2013). FDA Approved Medications for the Treatment of Opiate Dependence: Literature Reviews on Effectiveness and Cost-Effectiveness. Chevy Chase, MD: American Society of Addiction Medicine. Available at http://www.asam.org/docs/defaultsource/advocacy/aaam_implications-for-opioid-addiction-treatment_final


Leave a comment
  1. Sarah Mar 20, 2019 - 07:37 PM
    Adidas gazelle mens Cactus jack Air Force Pandora Necklace chain Pandora greece charm Red white and blue Adidas shoes Pandora stackable rings Trendy Nike sneakers 2019 Nike downshifter 7 boys Nike zoom Adidas supernova sequence Boost 8 Nike Air Max 1 mens Genuine Air Max 2019 Habanero red Air Max 270 Alabama Nike Air mags Pandora promotions 2017 Canada Air Max shoes 2019 Kohls Nike flex 2019 rn Nike Air Jordan women Louboutin so kate black Brown Nikes Nike Cortez black and red Nike kd 10 bhm Nike Vapormax flyknit moc 2 Womens Ultra Boost black Nasa Air Force 1 Christian Louboutin pigalle follies patent leather pumps Plain black Adidas trainers Nike free rn 2019 women's running shoe Asics gel resolution 6 mens Orange camo af1 Air Max 1 sale Womens black Adidas shoes Nike air zoom spiridon 16 Pandora locket charm Adidas seeley Nike flex experience 5 Nike las vegas Nike outlet viejas Undefeated Air Max Lebron 15 rust pink 2019 black and purple Air Max Pandora rope bracelet Yeezy Boost 350 v2 butter Jordan 1 release Travis scott Air Force 1 release date Top ten Nike shoes Nike free rn 2019 green Nike sf af1 on feet Jordan 4 bred Cheap Pandora rings Nike Air Max black and purple 2019 New Nike running shoes 2017 Pandora hockey charm Air Force one low Air Max 90 black white Adidas cloudfoam lite Nike Air Force 1 university red Nike zoom fly sp on feet Nike air presto linen Pandora charms sale clearance Baby boy Nike Pandora midnight star ring Nike Vapormax plus men's Pandora promo code 2019 Nike Air Max training shoes Pandora eye charm Pandora jewelry store near me Adidas originals busenitz Asics gel venture Nike womens yellow running shoes Asics gel kinsei 6 Nike flex 2019 run womens black Nike react review Toddler boy Nikes Asics nimbus Niketown soho Adidas deerupt Pandora dolphin charm Nike discount code may 2019 Nike 95 ultra essential Adidas Ultra Boost Off White sneakers new All white Nikes mens NMD xr1 white Green Adidas shoes Authentic Red Bottoms for cheap Nike juvenate Adidas NMD runner Nike outlet nj New Air Max 2019 women's Nike id Adidas paris Pandora infinity charm Air Jordan 11 black Adidas high tops women NMD black pink How to clean Pandora jewelry Mens purple Nike basketball shoes Adidas boston Boost Jordan 4 black Air Force 1s mens Nike Air Max 90 grey Womens Nike zoom winflo 4 Adidas t Womens black Adidas trainers Adidas Superstar womens Pandora leo charm Pandora floating locket charms NMD monochrome Adidas sneakers for men Christian Louboutin customer service Nike kawa slide NMD_r2 primeknit shoes Adidas shoes NMD r1 Lebron 6s Nike Air Max 2017 green Nike space shoes Nike Air Max guile Nike flyknit womens Nike store mlk Nike Vapormax flyknit Restock Yeezy Orange af1 Custom Yeezy 750 Boys Jordan shoes Nike outlet chicago Nike vapor ultrafly keystone Girls Nike shoes size 12 Yeezysupply Nike flex experience rn 6 women's Nike Air Max plus red and black Tan Nikes Womens free run 2019 Nike kaishi 2.0 Pandora stackable rings Yeezy busta Nike Air Max sports direct Multicolor Lebron 15 Nike air vapor plus Olive Air Force ones Nike Air Max multicolor Lebron 15s Red Adidas mens shoes new Pandora charms 2019 Nike Air Max 90 kids Utility Vapormax Adidas flex shoes Yeezy Boost 350 size 13 Black and red Air Force ones Men's Nike react hyperdunk 2019 low Asics womens size 12 Nike duckboot Air Max 97 gym red Nike code Air Max 95 og 2019 Nike Huarache rainbow Nike epic react colorways Lebron James flip flops Vintage Adidas top Adidas for girls Pandora jewelry charms Lebron James christ the king Christian Louboutin red heels Nike men's revolution 3 running shoe Nike sb size 14 Popular Adidas shoes Nike Air Max 95 ultra se black Nike lunarepic Nike run swift review Air Max 97 suede Nike tn size 5 Nike Air Max Flyknit womens 2019 All red Adidas Superstar Pink Lebron 15 Adidas NMD r1 Nike Air Max 97s Red Nikes Vapor plus Nike Blue Nike shoes mens Nike Air Max 97 junior sale Nike Air Max 1 blue Adidas beckenbauer trainers Kobe bryant shoes Nike turf shoes Pandora twist of fate ring Jordan 12 taxi Pandora store Nike men's fingertrap max Adidas art Nike air Vapormax womens pink Adidas shell toe Pandora best friend charm Purple Adidas women Nike Air Max 97 red Ultra Boost uncaged grey Yeezy Boost v2 Yeezy Boost 350 v2 butter Nike hyperdunk white Yeezy 350 v2 zebra Jordan 4 eminem Adidas Pure Boost ltd Mens green Adidas shoes Air Max 97 gold Nike air mag price Nike 27c Adidas metallic Superstar Yeezy london Air Max 97 glitter Yeezy 350 2019 Where to buy Red Bottom shoes Ultra Boost 2.0 core black Adidas NMD womens pink Nike sneakers for women Yeezy cream Pandora flower ring Sply 350 trainers Pandora feather earrings Nike lunarepic low 2 Nike Air Max orange and black 2019 Air Max mens Nike react hyperdunk 2019 Adidas usa Nike tanger Asics gel tech walker neo 4 Nike flywire Green Air Force ones Nike shoes lebron 2019 Lebron 11 colorways Pink Air Force ones mens Off White Presto review Nike 2019 doernbecher Nike sb zoom janoski Christian Louboutin low heels Asics gel kayano 22 women's Hello kitty Pandora charm Sb dunks Pandora codes 2019 Best looking Adidas shoes Adidas NMD white boys Adidas falcon elite 5 Nike Air Max 90 mens Nike Air Max thea womens black Pandora letters Jd Yeezy Tn Vapormax grey Nike Air Max blue and white Air Force 1 2018 Asics gel flux White Nikes mens Nike free rn 2019 anthracite Yeezy Boost 350 v2 white Off White Vapormax womens Grey NMDS Womens af1 Yeezy moonrock Nike Air Max 90 Nike the grove Pandora silver bracelet Adidas sl76 Adidas shell toe girls Womens Nike slides on sale January birthstone Pandora All grey Nike Air Max Nike sb shoes womens Pandora jewelry promotions 2019 Nike sb blazer black Michael Jordan dunk Yeezy size 9 Womens red Asics Pandora jewelry promotions 2019 Nike girls tennis Nike non slip shoes Nike men's flex 2019 rn running shoes All red Huaraches Adidas new 2019 shoes Men's Vapormax shoes Adidas Originals Superstar girls Yeezy shoes store Yeezy size 11.5 Air Force 1 low men's Nike free rn 2019 Adidas adilette slides Pink NMDS Adidas Originals pharrell Pandora love knot Off White mission statement Adidas Yeezy sale Yeezy drop 2019 Pandora april birthstone charm Off White shoes for cheap Nike 9c Reigning champ Ultra Boost Adidas spezial shoes Nike Air Max infrared Off white Nike Jordan 1 Nike Huarache ultra Air Presto off white Adidas Originals store near me Goyard beverly hills Nike Cortez white black Yeezys kids size 5 Red Bottom shoes Nike mesh shoes Pandora chinese charm Dark blue Air Force ones Nike Air Jordan vi Christian Louboutin shoe size Adidas NMD camouflage Nike Air Max womens Womens Nike shoes size 7 Green Huaraches kids Lebron 14 low black Pandora sale 70 off Pharrell x Adidas NMD human race Fragment x Off White Air Force marathon Nike flex supreme tr 3 Nike hyperdunk 2015 womens Nike zoom spiridon Nike duel racer review Purple and white Adidas Pastel Air Max 97 Niketown new york Nike 95 Vapormax Michigan wolverines Nike shoes Nike Off White Vapormax sandals Grape Vapormax Nike men's air versitile ii basketball shoes Marshalls shoes Nike Nike free rn 2019 pink Nike 97 white womens Nike son of force Kyrie Irving shoes 2018 Vapormax Nike factory Black Friday 2019 Nike Vapormax 2019 Adidas Yeezy Boost 350 v2 Nike foamposite red White on white Adidas 2018 Nike flyknit Images of Pandora bracelets Nike react hyperdunk 2017 flyknit Nike womens flyknit free Nike 2019 free run Asics nimbus 19 mens Nike air Vapormax Nike Air Max classic mens Off White Blazer combination Nike Blazer low womens Adidas NMD r1 womens Nike 270 mens Asics wide tennis shoes Air Huarache All white Air Forces Huarache sandals Nike Cortez Nike Air Force 1 low white Pandora guitar charm Nike Air Max zero essential Women's Nike reax run 5 running shoes Lebron shoes Adidas wear Nike junior presto fly trainer Nike 90s
  2. Cynthia Callahan May 08, 2018 - 09:41 PM

    I was placed in one of these programs when I had surgery and was taking opioids afterwards. I took them for 6 months and had no problems with addiction. I never had a euphoric effect from the medication and stopped taking them when I no longer needed them. Because I had the prescription filled by 3 providers (within the same orthopedic surgical group) I was targeted as an addict and placed on the restricted recipient program in Minnesota (even though I was no longer taking the medication).

    I have had nothing but problems trying to obtain medical care since then. They refuse prescriptions from my selected service providers and referrals need to be sent multiple times. If you can't get an appointment with your service provider the only option is an emergency room for treatment. I wonder how many people have given up trying to obtain healthcare on these programs. I have no doubt the programs save money in the long run, they kill off the recipients.

    Leave a comment