North Carolina § 58-51-37 - 1. Lock-in program for certain controlled substances.

§ 58-51-37. 1. Lock-in program for certain controlled substances.

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: 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. 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. 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. An insurer may develop a lock-in program as part of a health benefit plan for insureds who meet any of the following criteria: Have filled six or more prescriptions for covered substances in a period of two consecutive months. Have received prescriptions for covered substances from three or more health care providers in a period of two consecutive months. Are recommended to the insurer as a candidate for the lock-in program by a health care provider. A lock-in program developed pursuant to subsection (c) of this section shall comply with all of the following: 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. 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. 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. 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. History (2018-49, s. 3(b).) Editor's Note. - This section was enacted as G.S. 58-31-37.1 and was redesignated as G.S. 58-51-37 .1 at the direction of the Revisor of Statutes. Session Laws 2018-49, s. 3(d), made this section effective June 22, 2018, and applicable to health benefit plan contracts issued, renewed, or amended on or after that date.