New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 570 - PHARMACEUTICAL SERVICES
Section He-W 570.07 - Pharmacy Lock-In Program

Universal Citation: NH Admin Rules He-W 570.07

Current through Register No. 40, October 3, 2024

(a) The department shall conduct recipient utilization reviews in accordance with He-W 520.04 and in consideration of the recommendations of the DUR board pursuant to He-C 5010.07(j) to determine if prescribed drugs are being utilized at a frequency or amount that results in a demonstrated pattern of excessive or inappropriate utilization of services.

(b) If it is determined from the utilization review in (a) above that the recipient utilized excessive or inappropriate pharmaceutical services, the recipient shall be enrolled into the pharmacy lock-in program pursuant to 42 CFR 431.54(e) , for a 12-month period.

(c) Recipients shall be notified by the department in writing of their enrollment into the pharmacy lock-in program at least 30 days prior to the effective date of their enrollment.

(d) The written notification to the recipient shall include:

(1) The date of their enrollment into the pharmacy lock-in program;

(2) Instructions for the recipient to choose a primary pharmacy, within 21 days of the date of the written notification, as their only source for obtaining all prescribed drugs;

(3) Notification that if the recipient fails to choose a primary pharmacy in accordance with (d) (2) above, or if the pharmacy is unwilling or unable to be the primary pharmacy, the department shall select a primary pharmacy for the recipient based on the recipient's previous pharmacy use and geographical location; and

(4) The recipient's rights to appeal pharmacy lock-in and request a fair hearing within 30 days of the date on the written notification, pursuant to 42 CFR 431.54(e) , and in accordance with He-C 200, if the recipient disagrees with the department's decision.

(e) If the primary pharmacy is selected by the recipient pursuant to (d) (2) above, the department shall notify the primary pharmacy in writing of its selection at least 7 business days prior to the effective date of the recipient's enrollment into the pharmacy lock-in program.

(f) If the primary pharmacy is selected by the department pursuant to (d) (3) above, the department shall notify the recipient and the primary pharmacy in writing of its selection at least 7 business days prior to the effective date of the recipient's enrollment into the pharmacy lock-in program.

(g) Recipients enrolled in the pharmacy lock-in program shall have the following service restrictions:

(1) Recipients shall be identified through a claims transaction from the PBM to the non-primary pharmacy as having a service restriction that states "Medication Control. Recipient Restricted to Primary Pharmacy";

(2) Except as set forth in (g) (3) below, only the recipient's primary pharmacy may receive payment from the department for drugs dispensed to a recipient with the restriction set forth in (g) (1) above; and

(3) If a pharmacy other than the primary pharmacy determines that a recipient is unable to access his or her primary pharmacy due to the recipient being out of area, or due to the primary pharmacy not being open or not having the prescribed drug available, the non-primary pharmacy may contact the PBM to request permission to dispense a 72-hour emergency supply of a drug to a restricted recipient in accordance with 42 CFR 431.54(e) (3) .

(h) Recipients enrolled in the pharmacy lock-in program may change their primary pharmacy only:

(1) Upon the request of the primary pharmacy;

(2) If the recipient moves; or

(3) If the primary pharmacy disenrolls from the medicaid program.

(i) If the department implements a change pursuant to (h) above, the department shall notify the new primary pharmacy and the recipient, in writing, of the effective date of the change.

(j) Eligible recipients who become ineligible for medicaid services during their 12-month pharmacy lock-in enrollment period, shall be reinstated into the pharmacy lock-in program for the balance of the enrollment period, lasting until the originally calculated ending date, should they again become eligible for medicaid services prior to the originally calculated lock-in end date.

(k) Within the last 3 months of the 12 month lock-in period, the department shall conduct a review of the recipient's prior 6 months of utilization of pharmaceutical services pursuant to (a) above and in consideration of the recommendations of the DUR board pursuant to He-C 5010.07(j) , to determine whether the recipient has continued to utilize excessive or inappropriate pharmaceutical services.

(l) If the utilization review in (k) above no longer shows a demonstrated pattern of excessive or inappropriate utilization of pharmacy services, the recipient shall be released from the lock-in.

(m) Recipients shall be notified by the department in writing of their release from the pharmacy lock-in program within 30 days after the end date of their lock-in.

(n) The written notification to the recipient shall include:

(1) The date that the recipient's lock-in ended; and

(2) Notification that the recipient may utilize any medicaid enrolled pharmacy.

(o) If the utilization review in (k) above shows no improvement in the recipient's pattern of excessive or inappropriate utilization of pharmacy services, the recipient shall continue to be enrolled in the lock-in program for an additional 24 months.

(p) Recipients shall be notified by the department in writing of of their continued enrollment into the pharmacy lock-in program in accordance with He-W 570.07(c) and (d) .

(q) Within the last 3 months of the 24 month lock-in period, the department shall conduct a review in accordance with (k) above.

(r) If the utilization review in (k) above shows some improvement in the recipient's pattern of excessive or inappropriate utilization of pharmacy services, the recipient shall continue to be enrolled in the lock-in program for an additional 12 months after completion of the prior 12-month lock-in.

(s) Recipients shall be notified by the department in writing of their continued enrollment into the pharmacy lock-in program in accordance with He-W 570.07(c) and (d) .

(t) Within the last 3 months of the 12 month lock-in period, the department shall conduct a review in accordance with (k) above.

(See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #8636, eff 5-26-06; ss by #9586, eff 11-4-09

Disclaimer: These regulations may not be the most recent version. New Hampshire may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.