Medicaid Lock-in Program
If a member meets the criteria for the pharmacy and/or PCP Lock-In Program, the following initial communications are sent:
- An intervention communication to the physician
- A notification letter to the member
- A notification letter to the pharmacy
Members will be enrolled into the Lock-In Program for a period up to 12 consecutive months (or longer if necessary to comply with state requirements). After this time frame, recipients will be released from the program.
- Subsequent, ongoing communications with members, caregivers, prescribers, and pharmacies are based on how the member is managing within the Lock-In Program.
- Members who are locked in are also referred to care management for further support and guidance for managing their pain.
- If at any time if the limitation is determined not to be necessary, the member receives an alternative second notice indicating that the limitation has been removed.
- Reevaluation will occur six months after the end of the initial lock-in period.
Medicare Opioid Drug Management Program (Opioid DMP) Program
Once a member is identified as being potentially at risk:
- The member’s case file is reviewed by an Opioid DMP Clinical Pharmacist
- The member is offered medication therapy management services, including a comprehensive medication review with a clinical pharmacist.
If a member is determined to be “at risk” they are placed in our opioid drug management program and will be subject to access limitations. Access limitations may include:
- Placement of a point-of-sale (POS) claim edit for the frequently abused drug(s) to include prior authorization requirements, quantity limits and strengthening utilization review criteria for opioid prescriptions, and/or
- Locking the member into specific prescriber(s) and/or pharmacy(ies) with prescriber agreement.