Wis. ForwardHealth Online Handbook, Hospice, Topic #274

Overview of the Pharmacy Services Lock-In Program

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 for controlled substances. The Pharmacy Services Lock-In Program focuses on the abuse or misuse of prescription

benefits for controlled substances. Abuse or misuse is defined under Recipient Duties in Wis. Admin. Code § DHS 104.02.

Coordination of member health care services is intended to:

• Curb the abuse or misuse of controlled substance medications.

• Improve the quality of care for a member.

• Reduce unnecessary physician utilization.

The Pharmacy Services Lock-In Program focuses on the abuse or misuse of prescription benefits for controlled substances.

Abuse or misuse is defined under Recipient Duties in Wis. Admin. Code § DHS 104.02. The abuse and misuse definition

includes:

• Not duplicating or altering prescriptions

• Not feigning illness, using false pretense, providing incorrect enrollment status, or providing false information to obtain

service

• Not seeking duplicate care from more than one provider for the same or similar condition

• Not seeking medical care that is excessive or not medically necessary

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.

Members enrolled in the Pharmacy Services Lock-In Program will be locked into one pharmacy where prescriptions for

restricted medications must be filled and one prescriber who will prescribe restricted medications. Restricted medications are most

controlled substances, carisoprodol, and tramadol. Referrals will be required only for restricted medication services.

Fee-for-service members enrolled in the Pharmacy Services Lock-In Program may choose physicians and pharmacy providers

from whom to receive prescriptions and medical services not related to restricted medications. Members enrolled in an HMO

must comply with the HMO's policies regarding care that is not related to restricted medications.

Referrals of members as candidates for lock-in are received from retrospective DUR (Drug Utilization Review), physicians,

pharmacists, other providers, and through automated surveillance methods. Once a referral is received, six months of pharmacy

claims and diagnoses data are reviewed. A recommendation for one of the following courses of action is then made:

• No further action.

• Send an intervention letter to the physician.

• Send a warning letter to the member.

• Enroll the member in the Pharmacy Services Lock-In Program.

Medicaid, BadgerCare Plus, and SeniorCare members who are candidates for enrollment in the Pharmacy Services Lock-In

Program are sent a letter of intent, which explains the restriction that will be applied, how to designate a primary prescriber and a

pharmacy, and how to request a hearing if they wish to contest the decision for enrollment (that is, due process). If a member fails

to designate providers, the Pharmacy Services Lock-In Program may assign providers based on claims' history. In the letter of

intent, members are also informed that access to emergency care is not restricted.

Letters of notification are sent to the member and to the lock-in primary prescriber and pharmacy. Providers may designate

alternate prescribers or pharmacies for restricted medications, as appropriate. Members remain in the Pharmacy Services Lock-In Program for two years. The primary lock-in prescriber and pharmacy may make referrals for specialist care or for care that

they are otherwise unable to provide (for example, home infusion services). The member's utilization of services is reviewed prior

to release from the Pharmacy Services Lock-In Program, and lock-in providers are notified of the member's release date.

Excluded Drugs

The following scheduled drugs will be excluded from monitoring by the Pharmacy Services Lock-In Program:

• Anabolic steroids

• Barbiturates used for seizure control

• Lyrica

• Provigil and Nuvigil

• Weight loss drugs

Pharmacy Services Lock-In Program Administrator

The Pharmacy Services Lock-In Program is administered by Acentra. Acentra may be contacted by phone at 877-719-3123, by

fax at 800-881-5573, or by mail at the following address:

Pharmacy Services Lock-In Program

c/o Acentra

PO Box 3570

Auburn AL 36831-3570

Pharmacy Services Lock-In Prescribers Are Required to Be Enrolled in

Wisconsin Medicaid

To prescribe restricted medications for Pharmacy Services Lock-In Program members, prescribers are required to be enrolled in

Wisconsin Medicaid. Enrollment for the Pharmacy Services Lock-In Program is not separate from enrollment in Wisconsin

Medicaid.

Role of the Lock-In Prescriber and Pharmacy Provider

The lock-in prescriber determines what restricted medications are medically necessary for the member, prescribes those

medications using their professional discretion, and designates an alternate prescriber if needed. If the member requires an

alternate prescriber to prescribe restricted medications, the primary prescriber should complete the Pharmacy Services Lock-In

Program Designation of Alternate Prescriber for Restricted Medication Services (F-11183 (02/2025)) form and return it to the

Pharmacy Services Lock-In Program and to the member's HMO, if applicable.

To coordinate the provision of medications, the lock-in prescriber may also contact the lock-in pharmacy to give the pharmacist

(s) guidelines as to which medications should be filled for the member and from whom. The primary lock-in prescriber should also

coordinate the provision of medications with any other prescribers they have designated for the member.

The lock-in pharmacy fills prescriptions for restricted medications that have been written by the member's lock-in prescriber(s)

and works with the lock-in prescriber(s) to ensure the member's drug regimen is consistent with the overall care plan. The lock-in

pharmacy may fill prescriptions for medications from prescribers other than the lock-in prescriber only for medications not on the

list of restricted medications. If a pharmacy claim for a restricted medication is submitted from a provider who is not a designated

lock-in prescriber, the claim will be denied.

Designated Lock-In Pharmacies

The Pharmacy Services Lock-In Program pharmacy fills prescriptions for restricted medications that have been written by the

member's lock-in prescriber(s) and works with the lock-in prescriber(s) to ensure the member's drug regimen is consistent with

the overall care plan. The lock-in pharmacy may fill prescriptions for medications from prescribers other than the lock-in

prescriber only for medications not on the list of restricted medications. If a pharmacy claim for a restricted medication is

submitted from a provider who is not a designated lock-in prescriber, the claim will be denied.

Alternate Providers for Members Enrolled in the Pharmacy Services Lock-In Program

Members enrolled in the Pharmacy Services Lock-In Program do not have to visit their lock-in prescriber to receive medical

services unless an HMO requires a primary care visit. Members may see other providers to receive medical services; however,

other providers cannot prescribe restricted medications for Pharmacy Services Lock-In Program members unless specifically

designated to do so by the primary lock-in prescriber. For example, if a member sees a cardiologist, the cardiologist may

prescribe a statin for the member, but the cardiologist may not prescribe restricted medications unless they have been designated

by the lock-in prescriber as an alternate provider.

A referral to an alternate provider for a Pharmacy Services Lock-In Program member is necessary only when the member needs

to obtain a prescription for a restricted medication from a provider other than their lock-in prescriber or lock-in pharmacy.

If the member requires alternate prescribers to prescribe restricted medications, the primary lock-in prescriber 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 Service Lock-In Program and the member's HMO.

Designated alternate prescribers are required to be enrolled in Wisconsin Medicaid.

Claims from Providers Who Are Not Designated Pharmacy Services Lock-In Providers

If the member brings a prescription for a restricted medication from a non-lock-in prescriber to the designated lock-in pharmacy,

the pharmacy provider cannot fill the prescription.

If a pharmacy claim for a restricted medication is submitted from a provider who is not the designated lock-in prescriber, alternate

prescriber, lock-in pharmacy, or alternate pharmacy, the claim will be denied. If a claim is denied because the prescription is not

from a designated lock-in prescriber, the lock-in pharmacy provider cannot dispense the drug or collect a cash payment from the

member because the service is a nonreimbursable service. However, the lock-in pharmacy provider may contact the lock-in

prescriber to request a new prescription for the drug, if appropriate.

To determine if a provider is on file with the Pharmacy Services Lock-In Program, the lock-in pharmacy provider may do one of

the following:

• Speak to the member.

• Call Acentra.

• Call Provider Services.

• Use the ForwardHealth Portal.

Claims are not reimbursable if the designated lock-in prescriber, alternate lock-in prescriber, lock-in pharmacy, or alternate lock-in pharmacy provider is not on file with the Pharmacy Services Lock-In Program.

For More Information

Providers may call Acentra with questions about the Pharmacy Services Lock-In Program. Pharmacy providers may also refer to

the list of restricted medications data table or call Provider Services with questions about the following:

• Drugs that are restricted for Pharmacy Services Lock-In Program members

• A member's enrollment in the Pharmacy Services Lock-In Program

• A member's designated lock-in prescriber or lock-in pharmacy