§ 58-51-37.1. Lock-in program for certain controlled substances.

531 words·~2 min read·/nc/chapter-58/58-51-37-1

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(a)As used in this section, "covered substances" means 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:

(1)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.

(2)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.

(b)As used in this section, "lock-in program" means a requirement that an insured select a single prescriber and a single pharmacy for obtaining covered substances under a health benefit plan.

(c)An insurer may develop a lock-in program as part of a health benefit plan for insureds 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 health care providers in a period of two consecutive months.

(3)Are recommended to the insurer as a candidate for the lock-in program by a health care provider.

(d)A lock-in program developed pursuant to subsection

(c)of this section shall comply with all of the following:

(1)An insured shall not be subject to the lock-in program until the insurer has notified the insured in writing that the insured will be subject to the lock-in program.

(2)An insured 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 participating in the health benefit plan provider network. For any insured who fails to select a single prescriber, the insurer shall use algorithmic guidelines to assign the insured a single prescriber from a list of prescribers participating in the health benefit plan provider network. For any insured who fails to select a single pharmacy, the insurer shall use algorithmic guidelines to assign the insured a single pharmacy from a list of pharmacies participating in the health benefit plan provider network.

(3)An insured 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 health benefit plan that are not covered substances. An insured who is subject to a lock-in program retains all rights under G.S. 58-51-37 to obtain prescription drugs covered by a health benefit plan that are not covered substances.

(e)An insurer's use of a lock-in program developed pursuant to subsection

(c)of this section is not a violation under G.S. 58-51-37. (2018-49, s. 3(b).)