Pharmacy Lock-In Program

Introduction

The Medicaid Pharmacy Lock-In Program has been established by the Division of Medical Services to restrict recipients whose utilization of Medical Services is documented as being excessive. Recipients are "Locked-In" to specific providers in order to monitor services received and reduce unnecessary or inappropriate utilization. This program is intended to prevent Medicaid recipients from obtaining excessive quantities of prescribed drugs through multiple visits to physicians and pharmacies.

Legal Basis

The Code of Federal Regulations 42 CFR 440.230 (d) states the following:

"The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures."

Enrollment of Recipients

Whenever Medicaid records indicate that recipient utilization is excessive or inappropriate with reference to medical need, the Division of Medical Services may require an individual to designate a physician and pharmacy of choice for exclusive service in order to:

• Protect the individual's health and safety;
• Provide continuity of medical care;
• Avoid duplication of service by providers;
• Avoid inappropriate or unnecessary utilization of Medicaid as defined by community practices and standards; and,
• Avoid excessive utilization of prescription medications.

Excessive utilization of prescription medications will be determined from published current medical and pharmacological references to include Physician Desk Reference published by Medical Economics Company and the Pharmacological Basis of Therapeutics published by MacMillan Company.

The Department selects for enrollment in the Medicaid Pharmacy Lock-In Program recipients who have a documented history of obtaining excessive or inappropriate prescribed drugs under the Medicaid Program.

Recipients will be given a written notice ( MA/DUR-1) of his/her excessive or inappropriate utilization thirty days prior to the implementation of the restriction and will be requested to choose a primary pharmacy/physician as a single source of medical care.

The notification will also advise the individual that failure to cooperate in this program will necessitate the Department's designating a physician/pharmacy for the individual based on the recipient's previous use and geographical location.

The notification will include the individual's right to request a fair hearing within 30 days if he/she disagrees with the findings and the Department action.

Pharmacy Lock-In

REVS Recipients who are in the Medicaid Pharmacy Lock-In Program are identified through the Recipient Eligibility Verification System (REVS).

Responsibilities of the Primary Pharmacy of Choice

The Primary Pharmacy of Choice must monitor the drug utilization of each restricted recipient and must exercise sound professional judgment when dispensing drugs in order to prevent inappropriate drug utilization by the recipient. When the pharmacist reasonably believes that the recipient is attempting to obtain excessive drugs through duplicate prescriptions or other inappropriate means, the pharmacist must contact the providing physician to verify the authenticity and accuracy of the prescription presented. Primary pharmacies that are found on review to be dispensing drugs in a manner that is inconsistent with professional standards may be subject to administrative action by the Department, including the recovery of payments.

Responsibilities of the Primary Care Physician

The Primary Care Physician is delegated the responsibility of overseeing the health care needs of the restricted recipient and providing all medically necessary care for which the recipient is eligible. The provider should be knowledgeable about the recipient's health care problems and aware of the care and services the recipient is receiving.

Change in Primary Pharmacy/Physician Recipient Status

A recipient may change his/her primary pharmacy/physician for reasonable cause by notifying the Medicaid Pharmacy Lock-In Program and choosing a new primary pharmacy/physician.

If, after review of the recipient's drug-usage profile, it is determined by the Medicaid Pharmacy Lock-In Program that restriction of the recipient to the primary pharmacy is no longer appropriate, the restriction will be removed. Such review will not take place prior to 15 months from the date of enrollment.