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Lock-in and Opioid Drug Management Program Opioid DMP Programs

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.
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Last Updated On: 12/13/2020
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