Client Overutilization Program
The Client Overutilization Program (COUP, also known as “Lock-In”) is a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate use of care or services. This program provides a post-payment review process allowing for the review of Medicaid client utilization profiles. It identifies excessive patterns of utilization in order to rectify over-utilization practices of clients. The Client Over-Utilization Program will restrict clients to one designated pharmacy and primary care physician when there is documented evidence of abuse or over-utilization of allowable medical benefits.
Who is subject to COUP placement?
Any Medicaid recipient whose utilization of Medicaid benefits without medical necessity has exceeded any one of the following parameters during a three-month period:
- Use of sixteen or more prescriptions;
- Use of three or more pharmacies;
- Use of three or more drugs in the same therapeutic category, i.e., Oxycodone, Oxycontin, Hydrocodone;
- Has excessive ER and physician visits; OR
- A referral or analysis indicates possible overutilization
How does it work?
Potential COUP client’s usage is reviewed on a quarterly basis. Clients that are minors, i.e., foster children, EPSDT recipients or in nursing facilities are excluded and are not evaluated for COUP. When a client is placed in COUP, the client has one prescribing provider (PCP) and can pick up prescriptions at only one designated pharmacy. Sometimes a PCP may not want to prescribe psychiatric or pain management medications, in this case, two providers are allowed to prescribe for the client, i.e., the PCP and psychiatrist. Clients are placed in the COUP for an initial twelve-month period.
Can I request that placement be reviewed?
Clients can appeal the decision. During time of appeal the client will not be placed in the COUP.
APS Health Care
1-888-454-7686, option 2