§ 58‑51‑37.1.  Lock‑in program for certain controlled substances.

(a) 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:

(1) 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.

(2) 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.

(b) 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.

(c) An insurer may develop a lock‑in program as part of a health benefit plan for insureds who meet any of the following criteria:

(1) Have filled six or more prescriptions for covered substances in a period of two consecutive months.

(2) Have received prescriptions for covered substances from three or more health care providers in a period of two consecutive months.

(3) Are recommended to the insurer as a candidate for the lock‑in program by a health care provider.

(d) A lock‑in program developed pursuant to subsection (c) of this section shall comply with all of the following:

(1) 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.

(2) 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.

(3) 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.

(e) 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. (2018‑49, s. 3(b).)