Pharmacy Lock-In Program
Customize your policy alerts
Sign up for carolina_complete_health_inc Policy CC.PHAR.18 alerts
Get alerted when Policy CC.PHAR.18 changes without checking for updates manually.
Monitor payer policy activity
Defines criteria and processes for enrolling Medicaid members in a pharmacy lock-in to restrict controlled substance prescriptions to designated prescribers and pharmacies in order to prevent misuse and coordinate behavioral health care. Applies to Carolina Complete Health Medicaid members in North Carolina.
No material clinical or coverage changes in this revision.
Lock-In Coverage Criteria
Lock-in Initiation Criteria
Members will be enrolled when ALL of the following administrative criteria are met as determined by CCH pharmacy claims audit or referral:
Lock-in initiation
Lock-in triggers
- Trigger A: Filled ten (10) or more benzodiazepine claims in two (2) consecutive months>= 10 fills in 2 consecutive months
'When not medically necessary' applied per policy review
- Trigger B: Filled ten (10) or more opioid claims in two (2) consecutive months>= 10 fills in 2 consecutive months
'When not medically necessary' applied per policy review
- Trigger C: Received prescriptions for opioids and/or benzodiazepines from four (4) or more prescribers in two (2) consecutive months>= 4 prescribers in 2 consecutive months
'When not medically necessary' applied per policy review
CCH reviews utilization profile based on these sources
Enrollment, Maintenance, and Exceptions
Once enrolled, the following coverage and operational rules apply:
Enrollment and maintenance
- Notice and appeal: Member receives notification of intent to lock and appeal rights prior to lock-in taking effect; member is not locked during the pendency of a timely appeal
Providers receive correspondence and may request medical necessity review for members ages 18–21
- Assignments: CCH will notify and assign one (1) prescriber and one (1) pharmacy for controlled substances (opioids and/or benzodiazepines) in the pharmacy claims system
Up to two prescribers may be allowed if member receives care from different providers; CCH may recommend assignments and members may request changes through CCH
- Emergency supply: A one-time emergency supply of up to a four (4) day prescription is allowed when member is locked to a different prescriber/pharmacy4-day supply, once per 12-month period during the 2-year lock
Pharmacy paid ingredient costs only; member may be responsible for any copayment
- Care coordination: CCH will provide care coordination for members in the Lock-In program with the member's medical home, primary care provider, or care providers
Exemptions and special procedures
- Clinical exemptions: Members with certain cancer diagnoses within the last 12 months or with sickle cell disease are exempt from lock-in
- Population exemptions: NC Health Choice members and Medicaid members under age 18 are not subject to the Lock-In program unless directed by the Division of Health Benefits
Members aged 18–21 will have provider correspondence describing medical necessity review option and requested response timeframe; reviews determined by CCH Medical Directors or designees
Providers must submit requested documentation within 10 calendar days for members ages 18–21 or the lock proceeds
Members with certain cancer diagnoses within the last 12 months and members with sickle cell disease are exempt from enrollment in the Pharmacy Lock‑In Program. This exemption is applied when those diagnoses are documented within the member’s record and will prevent assignment to a restricted prescriber or pharmacy under this program.
The Lock‑In Program is not applied to NC Health Choice members or to Medicaid members under age 18 unless directed by the Division of Health Benefits (DHB). For members aged 18–21, providers will receive correspondence if the member meets lock‑in criteria and are given the option to request a medical necessity exemption review; if no medical necessity request is submitted within 10 calendar days, the member will proceed to standard lock‑in initiation.
Lock‑in initiation is triggered when utilization meets stated thresholds "when not medically necessary" — for example, filling 10 or more benzodiazepine or opioid claims in two consecutive months, or receiving prescriptions from 4 or more prescribers in two consecutive months. The policy does not enumerate clinical definitions of "not medically necessary" within the threshold language; clinical exceptions and medical necessity reviews are handled separately by CCH Medical Directors or designees per the medical necessity review process.
Thresholds and Definitions
Provider Notifications, Assignments, and Actions
Lock‑in assignment and notification (not a prior auth)
This is not a prior authorization policy. CCH will assign one prescriber and one pharmacy for controlled substances (opioids and/or benzodiazepines) and will notify the prescriber and pharmacy of their assignment prior to the lock-in date; members receive notice and appeal rights before lock-in takes effect.
- CCH shall lock the member to one (1) prescriber and one (1) pharmacy for controlled substances categorized as opioids and/or benzodiazepines in the pharmacy benefit claims system.
- CCH will notify prescribers and pharmacy providers of their assignment to a member in the Lock‑in program prior to the Lock‑in date.
- Members will receive a notification of the intent to lock and appeal rights prior to lock‑in taking effect.
Prescriber limits and member requests
Members may be locked to up to two prescribers if care is managed by different providers. Members may request changes to the assigned prescriber or pharmacy by contacting CCH.
- If member receives care for conditions managed by different providers, they may be allowed to have a Lock‑in applied for up to two (2) prescribers.
- CCH may allow a member to request a change to the prescriber and pharmacy upon request made to CCH.
Provider correspondence and appeal/medical review
Providers will receive correspondence when their patient is identified for lock‑in and may submit medical necessity review requests where applicable; CCH notifies assigned prescribers and pharmacies prior to the lock‑in date.
- CCH will notify prescribers and pharmacy providers of their assignment to a member in the Lock‑in program prior to the Lock‑in date.
- Members who qualify for the lock‑in program will receive a notification of the intent to lock and appeal rights prior to lock‑in taking effect.
- Members shall have the opportunity to appeal the lock‑in decision and shall not be locked in during the pendency of the appeal if appealed timely.
Operational trigger summary and enrollment actions
Members who meet lock‑in triggers (for example: 10+ opioid or benzodiazepine fills in two consecutive months or receiving opioids/benzodiazepines from 4+ prescribers in two consecutive months) may be enrolled in the Lock‑In program and thus restricted to assigned prescriber(s) and pharmacy.
- Members will be enrolled in the lock‑in program for a period of two (2) years.
- CCH may auto‑enroll members transitioning from a prior plan with an active lock for the remaining duration.
- Emergency 4‑day supply allowed once per year if member is locked to a different prescriber/pharmacy.
Emergency Supply and Quantity Limits While Locked
Program Background
The Pharmacy Lock‑In Program is designed to detect and prevent abuse of the pharmacy benefit and to reduce excessive use of controlled substances while supporting members with care coordination and treatment needs. CCH uses monthly pharmacy claims audits and provider or pharmacy referrals to identify members who meet lock‑in criteria, and members transitioning from prior plans with an active lock may be auto‑enrolled for the remainder of their original lock period (up to 2 years).
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.