North Carolina General Statutes 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 N.C. Gen. Stat., 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 N.C. Gen. Stat. § 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 N.C. Gen. Stat. 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 N.C. Gen. Stat. § 108A-54.2, then the controlled substance is a covered substance under this section.
Terms Used In North Carolina General Statutes 108A-68.2
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Contract: A legal written agreement that becomes binding when signed.
- following: when used by way of reference to any section of a statute, shall be construed to mean the section next preceding or next following that in which such reference is made; unless when some other section is expressly designated in such reference. See North Carolina General Statutes 12-3
- in writing: may be construed to include printing, engraving, lithographing, and any other mode of representing words and letters: Provided, that in all cases where a written signature is required by law, the same shall be in a proper handwriting, or in a proper mark. See North Carolina General Statutes 12-3
(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 N.C. Gen. Stat. § 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(b), (c) Repealed by Session Laws 2021-62, s. 4.4, effective June 29, 2021.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).)