North Carolina General Statutes Chapter 108A. Social Services § 108A-68.2. Beneficiary lock-in program for certain controlled substances

(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 General Statutes, unless one of the following conditions are met:

(2) Lock-in program.--A requirement, consistent with 42 C.F.R. § 431.54(e), that restricts the number of prescribers from whom, and the number of pharmacies from which, a Medicaid beneficiary may obtain covered substances.

(2a) Medically necessary.--Having medical necessity as determined in accordance with 10A NCAC 25A .0201.

(3) Prepaid health plan or PHP.--As defined in G.S. 108D-1.

(1) Have filled 10 or more prescriptions for covered substances in a period of two consecutive months when not medically necessary.

(2) Have received prescriptions for covered substances from four or more prescribers in a period of two consecutive months when not medically necessary.

(3) Repealed by S.L. 2023-134, § 9E.23(a1), eff. Oct. 3, 2023.

(1) A beneficiary shall not be subject to the lock-in program until the PHP has notified the beneficiary in writing that the beneficiary will be subject to the lock-in program and the beneficiary has been provided an opportunity for a hearing.

(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 PHP's provider network.  In accordance with 42 C.F.R. § 431.54(e), the beneficiary may be allowed to select up to two prescribers and two pharmacies when medically necessary as designated by the State.  For any beneficiary who fails to select prescribers or pharmacies, the PHP shall use algorithmic guidelines to assign the beneficiary prescribers or pharmacies enrolled in the PHP's network.

(3) A beneficiary shall not be required to use the prescribers or pharmacies selected for the lock-in program to obtain prescriptions drugs covered by the Medicaid program or the PHP that are not covered substances.