Mo. Code Regs. tit. 22 § 10-2.160

Current through Register Vol. 49, No. 21, November 1, 2024.

Section 22 CSR 10-2.160 - Pharmacy Lock-in Program

PURPOSE: This rule establishes the policy of the board of trustees to implement a method to limit or restrict a member's use of his or her pharmacy benefit to a designated pharmacy.

PURPOSE: This amendment clarifies the definition of lock-in, the process for once the PBM determines a member has misutilized pharmacy benefits, eligibility of prescription coverage, and the pharmacy change request address.

(1) The Pharmacy Lock-In Program applies to all Missouri Consolidated Health Care Plan's (MCHCP) non-Medicare primary medical plan members that have been identified as misutilizing pharmacy benefits.

(2) Definitions. The following definitions apply to this program:

(A) Misutilization includes, but is not limited to: seeking excessive or unnecessary medical care from provider(s) and/or in quantities that exceed the levels that are considered medically necessary; the act of lending the pharmacy or medical ID card to non-eligible persons; and submitting forged documents to provider(s) or pharmacies for benefits;

(B) Lock-in: The method to limit or restrict a member to one (1) network pharmacy designated for the filling of specified prescription medication(s); and

(C) Lock-in period: A minimum of twelve (12) months from the effective date of the lock-in program as identified in the confirmation letter from the Pharmacy Benefit Manager (PBM). The lock-in period may be extended if it is determined that the member continues to misutilize benefits.

(3) MCHCP's PBM will identify and review potential cases of pharmacy benefit misutilization.

(4) Once the PBM determines a member has misutilized pharmacy benefits, the PBM will refer the member to MCHCP's vendor for case management and will send a letter notifying the member of their locked-in status. The letter will include the network pharmacy location designated to fill the specified prescription medication(s).

(5) Once locked-in to a designated network pharmacy, prescriptions for controlled substances and muscle relaxants will only be covered if filled at the designated pharmacy and otherwise eligible for coverage.

(6) Locked-in members may request a change to their designated pharmacy. Reasons for approval include, but are not limited to:

(A) The pharmacy is no longer in the member's demographic area;

(B) The pharmacy goes out of business;

(C) The pharmacy is no longer in the PBM network; or

(D) The pharmacy refuses to serve the member.

(7) Pharmacy change requests requirements-

(A) Must identify the member's (and dependent's, if applicable) name, the prescribing physician's name, and any applicable reason(s) relevant to the change request, including: the reason(s) the member believes his/her designated pharmacy should be changed and any other written documentation to support the member's belief that the pharmacy should be changed;

(B) Must be submitted in writing to:

Express Scripts

Drug Utilization Review Program

Mail Stop HQ3W03

One Express Way St. Louis, MO 63121

; and

(C) Pharmacy change requests will be reviewed and decided by the PBM.

22 CSR 10-2.160

Adopted by Missouri Register April 1, 2015/Volume 40, Number 07, effective 5/31/2015

Amended by Missouri Register April 1, 2016/Volume 41, Number 07, effective 5/31/2016