Pharmacy Lock-In Program
The mission of the OHCA Lock-In Program is to assist health care providers in monitoring potential abuse or inappropriate utilization of controlled prescription medications by SoonerCare members. When warranted, a member may be “locked-in”, and therefore required to fill all prescriptions at a single designated pharmacy in order to better manage his or her medication utilization.
How is a member referred for the Lock-In Program?
Referrals to the Lock-In Program come from several sources, including physicians, pharmacies, case workers, and OHCA staff members.
Who qualifies for referral to the Lock-In Program?
In order to qualify for lock-in review, an individual must be currently enrolled in SoonerCare or the Insure Oklahoma Individual Plan. Dual-eligible individuals who are enrolled in both SoonerCare and Medicare do not qualify for the Lock-In Program, as their pharmacy benefits are administered by a Medicare Part D drug plan.
How is the decision for a Lock-In made?
After a member is referred to the Lock-In Program, certain information is reviewed.
- Pharmacy Claims
- Emergency Room Claims
- Physician Claims
- History of Diagnoses
- Number of Prescribers and Their Specialties
- Number of hospital discharges
- Other information from past reviews
- Safety concerns
If the member’s utilization is determined to be potentially inappropriate, the lock-in process is started and members are assigned to a designated pharmacy and prescriber. The member is required to fill all prescriptions at a single pharmacy. The member is given the opportunity to choose a designated pharmacy and prescriber. This pharmacy and prescriber are contacted for consent prior to the member being locked-in.
How are referrals handled that do not meet the criteria for Lock-In?
An individual whose utilization merits concern, but does not fully meet the criteria for lock-in, is typically warned and/or monitored. If a decision is made to monitor without a warning, the case is reviewed again in three months, and a decision is made based on recent utilization patterns. In cases where a warning is warranted, a letter is sent to the member explaining that he or she is being monitored, and the reasons for which the warning has been issued.
Members that receive warnings are reviewed again in six months to evaluate recent utilization. If there is no improvement in utilization patterns, the member is entered into the lock-in program. If recent utilization has improved, the cases are closed.
Other options for cases that do not meet lock-in criteria include referral to other departments at OHCA. Some members may not utilize multiple pharmacies, but do receive controlled substances from multiple prescribers. These members are referred to OHCA staff members who can contact the member to discuss the need for a primary care physician or pain management. Members exhibiting indications of behavioral health issues or who need assistance finding psychiatric care may also be contacted by OHCA staff for assistance.