§ 108A‑68.2.  Beneficiary lock‑in program for certain controlled substances.

(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(b), (c) Repealed by Session Laws 2021‑62, s. 4.4, effective June 29, 2021.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.  (2018‑49, s. 3(a); 2021‑62, s. 4.4; 2022‑74, s. 9D.15(z).)