The purpose of the Pharmacy Services Lock-In Program is to coordinate the provision of health care services for members who abuse or misuse Medicaid, BadgerCare Plus, or SeniorCare benefits by seeking duplicate or medically unnecessary services, particularly prescriptions for controlled substances.
Coordination of member health care services is intended to do the following:
The Pharmacy Services Lock-In Program focuses on the abuse or misuse of controlled substance medications. Abuse or misuse is defined under Recipient Duties in DHS 104.02(5), Wis. Admin. Code. The abuse and misuse definition includes, but is not limited to, the following:
Members enrolled in the Pharmacy Services Lock-In Program are assigned to one primary care provider and one pharmacy to reduce unnecessary physician and pharmacy utilization and to discourage the non-medical or excessive use of prescription drugs.
The Pharmacy Services Lock-In program applies to members in fee-for-service as well as members enrolled in Medicaid SSI HMOs and BadgerCare Plus HMOs. Members remain enrolled in the Pharmacy Services Lock-In Program for two years and are continuously monitored for their prescription drug usage. At the end of the two-year enrollment period an assessment is made to determine if the member should continue enrollment in the Pharmacy Services Lock-In Program.
HID administers the Pharmacy Services Lock-In Program. Providers may contact the Pharmacy Services Lock-In Program by calling (800) 225-6998, extension 3045.
ForwardHealth operates a therapeutic DUR program designed to routinely monitor prescription drug use by members. The purpose of the DUR program is to identify potential clinical problems related to drug therapy and instances of potentially inappropriate drug use. When a member is identified through the DUR Program of suspected misuse of benefits, the member and the member's primary care provider(s) and pharmacy(s) may be notified.
Providers may also report members suspected of inappropriate prescription drug use by completing the Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use form and submitting the form to the Pharmacy Services Lock-In Program. When a provider refers a member for review, the Lock-In Program assesses the member's history of prescription drug claims to identify patterns that suggest possible misuse of prescription drugs.
The Pharmacy Services Lock-In Program monitors claims for pharmacy services and prescription drugs specifically. The Pharmacy Services Lock-In Program does not address other types of member fraud or misuse of benefits, such as misuse of the ForwardHealth identification card or excessive use of emergency room services.
Members enrolled in the Pharmacy Services Lock-In Program are required to designate one Lock-In pharmacy and one Lock-In primary care provider. If the member fails to designate Lock-In providers, ForwardHealth or the member's HMO choose for the member. During the member's enrollment in the Lock-In Program, the member may only receive services from the Lock-In primary care provider and the Lock-In pharmacy unless a referral is in place for another provider.
Fee-for-service members are assigned to one pharmacy and one primary care provider.
Members enrolled in an HMO are assigned to one pharmacy. The HMO is assigned as the member's designated Lock-In primary care provider. The HMO may in turn assign the member to one of the HMO's primary care providers.
The Lock-In pharmacy fills prescriptions that are medically necessary for the member and works with the Lock-In primary care provider or HMO to ensure the member's drug regimen is consistent with the overall care plan. The Lock-In pharmacy may fill prescriptions from prescribers other than the Lock-In primary care provider, but the Lock-In pharmacy must assure that prescriptions are medically necessary, are consistent with the care plan, and are not overlapping with other similar medications. If the member presents a prescription from an emergency room visit, the pharmacist at the Lock-In pharmacy must use his or her professional judgment as to whether or not to fill the prescription.
The Lock-In primary care provider determines what services are medically necessary for the member, provides those services at his or her discretion, and refers the member to other providers if needed. The Lock-In primary care provider also may contact the Lock-In pharmacy to give the pharmacist(s) guidelines as to which medications should be filled for the member and from whom.
If circumstances arise that require a change to the member's designated Lock-In pharmacy or primary care provider, contact the Pharmacy Services Lock-In Program at (800) 225-6998, extension 3045. Providers should allow at least one business day for the change to be applied to the member's file.
Referrals to other providers must be on file with the Pharmacy Services Lock-In Program before the member may receive services from any provider other than the designated Lock-In primary care provider or pharmacy. Services provided by providers other than the member's designated Lock-In primary care provider or pharmacy are not reimbursable unless a referral is on file with ForwardHealth.
If the member requires a referral, the Lock-In provider is required to complete the Pharmacy Services Lock-In Program Designation of Alternate Prescriber for Restricted Medication Services form. Referrals for fee-for-service members must be on file with the Pharmacy Services Lock-In Program. Referrals for HMO members must be on file with the Pharmacy Services Lock-In Program and the member's HMO.
Note: Emergency medical care is the only exception to the referral requirement.
ForwardHealth Portal member enrollment verification indicates a member's referral providers under the Pharmacy Services Lock-In Program. When a provider looks up member enrollment information, the Portal lists the member's Lock-In pharmacy, Lock-In primary care provider (when applicable), and referral providers.