N.J. Admin. Code § 10:74-1.5

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:74-1.5 - Provider lock-in program under managed care

(a) The managed care contractor may implement a lock-in program that restricts its enrollees to a single pharmacy and/or other provider type for a reasonable period of time. The program shall include policies, procedures, and criteria for establishing the need for the lock-in, which shall be prior approved by DMAHS and shall include the following components to the program:

1. Enrollees shall be notified prior to the lock-in and shall be permitted to choose or change providers for good cause;

2. The lock-in restrictions do not apply to emergency services furnished to the enrollee. A 72hour emergency supply of medication at pharmacies other than the designated lock-in pharmacy shall be permitted to assure the provision of necessary medication required in an interim/urgent basis when the assigned pharmacy does not immediately have the medication;

3. The lock-in restriction shall not apply while the beneficiary is receiving services on an inpatient basis, including, but not limited to, medical and pharmacy services provided in a hospital, rehabilitation facility, or nursing facility. Upon discharge from the inpatient facility, the beneficiary shall resume accessing services from the pharmacy and/or provider previously designated by the lock-in program.

4. Care management and education reinforcement of appropriate medication/provider use shall be provided. A plan for an education program for enrollees shall be developed and submitted to the Division for review and approval;

5. The continued need for lock-in shall be periodically evaluated by the contractor, but no less frequently than every two years, for each enrollee in the program;

6. Prescriptions from all participating prescribers shall be honored and shall not be required to be written by the PCP only; and

7. The contractor shall submit quarterly reports on Provider Lock-in participants, as determined by the DMAHS.

N.J. Admin. Code § 10:74-1.5

Amended by 51 N.J.R. 1359(a), effective 8/19/2019