§ 108A-68. 2. (Effective once contingency met — see note) Beneficiary lock-in program for certain controlled substances.
A Prepaid Health Plan may create a lock-in program for certain Medicaid beneficiaries, but it must give written notice first and let the beneficiary choose a single prescriber and pharmacy.
(a)The following definitions apply in this section: (1)Covered substances. — Any controlled substance identified as an opioid or benzodiazepine, excluding benzodiazepine sedative-hypnotics, contained in Article 5 of Chapter 90 of the General Statutes, unless one of the following conditions are met: a.If the Department of Health and Human Services specifically identifies the opioid or benzodiazepine as a substance excluded from coverage by the Medicaid Beneficiary Management Lock-In Program described in its Outpatient Pharmacy Clinical Coverage Policy adopted in accordance with G.S. 108A-54.2, then the opioid or benzodiazepine is not a covered substance under this section. b.If the Department of Health and Human Services specifically identifies a controlled substance contained in Article 5 of Chapter 90 of the General Statutes other than an opioid or benzodiazepine as a controlled substance covered by the Medicaid Beneficiary Management Lock-In Program described in its Outpatient Pharmacy Clinical Coverage Policy adopted in accordance with G.S. 108A-54.2, then the controlled substance is a covered substance under this section. (2)Lock-in program. — A requirement that a Medicaid beneficiary select a single prescriber and a single pharmacy for obtaining covered substances. (3)Prepaid health plan or PHP. — As defined in G.S. 108D-1. (b), (c) Repealed by Session Laws 2021-62, s. 4.4, effective June 29, 2021. (d)This section does not apply to any lock-in program for Medicaid beneficiaries who are not enrolled in a Prepaid Health Plan. (e)A Prepaid Health Plan may develop a lock-in program for Medicaid beneficiaries who meet any of the following criteria: (1)Have filled six or more prescriptions for covered substances in a period of two consecutive months. (2)Have received prescriptions for covered substances from three or more providers in a period of two consecutive months. (3)Are recommended as a candidate for the lock-in program by a provider. (f)A lock-in program developed pursuant to subsection (e) of this section shall comply with all of the following: (1)A beneficiary shall not be subject to the lock-in program until the Prepaid Health Plan has notified the beneficiary in writing that the beneficiary will be subject to the lock-in program. (2)A beneficiary subject to the lock-in program shall be given the opportunity to select a single prescriber and a single pharmacy from a list of prescribers and pharmacies in the Prepaid Health Plan’s provider network. For any beneficiary who fails to select a single prescriber, the Prepaid Health Plan shall use algorithmic guidelines to assign the beneficiary a single prescriber from a list of prescribers in the Prepaid Health Plan’s network. For any beneficiary who fails to select a single pharmacy, the Prepaid Health Plan shall use algorithmic guidelines to assign the beneficiary a single pharmacy from a list of pharmacies in the Prepaid Health Plan’s network. (3)A beneficiary shall not be required to use the single prescriber or single pharmacy selected for the lock-in program to obtain prescriptions drugs covered by the Medicaid program or the Prepaid Health Plan that are not covered substances. (g)A Prepaid Health Plan’s use of a lock-in program developed pursuant to subsection (e) of this section shall not constitute a violation of the terms of a contract between the Prepaid Health Plan and the Department that relate to a beneficiary’s ability to utilize a pharmacy of choice. History: History.2018-49, s. 3(a); 2021-62, s. 4.4; 2022-74, s. 9D.15(z).