The Bureau is authorized to implement and
maintain a pharmacy lock-in program designed to address member abuse or
overutilization. Activities which may indicate abuse or overutilization
justifying placement on lock-in or prior approval status include but are not
limited to the following:
(a) Forging or
altering a prescription for drugs.
(b) Selling TennCare paid prescription
(c) Failing to control
pharmacy overutilization activity while on lock-in status.
(d) Visiting multiple prescribers or
pharmacies to obtain controlled substances.
(e) Trading, swapping or selling a TennCare
(f) Failing to promptly
report the loss or theft of a TennCare card.
(g) Forging or altering a TennCare
(h) Knowingly providing
false, incomplete, inaccurate or erroneous information to provider(s) in order
to receive covered services for which the member is ineligible.
(i) Permitting the use of a TennCare card by
anyone other than the member to whom the card is assigned in order to receive
or attempt to receive services.
The TennCare pharmacy lock-in program
shall be administered by the Bureau. Monitoring of enrollee activities listed
in Paragraph (1) shall be conducted by the Bureau, the MCCs, including the PBM,
and the TennCare Office of Inspector General (OIG). When an enrollee has been
identified as having participatedin any abuse or overutilization activities,
including but not limited to the activities listed in Paragraph (1), the
enrollee's name shall be referred to the Bureau as appropriate or potentially
appropriate for the lock-in program as follows:
Appropriate for the lock-in program:
1. Any enrollee who has been identified by
the OIG as having been convicted of TennCare fraud or a drug-related
2. Any enrollee who has
used buprenorphine-containing products for office based opioid addiction
treatment within the previous six (6) months.
Potentially appropriate for the lock-in
1. Any enrollee who has been arrested
for TennCare fraud.
2. Any enrollee
who has been arrested for a drug-related offense.
Any enrollee who has obtained multiple
controlled substance prescriptions over a 90-day period that meet one of the
(i) The prescriptions
were filled at three (3) or more pharmacies and written by three (3) or more
(ii) The prescriptions
were filled at one (1) or more targeted pharmacies and written by two (2) or
prescriptions were filled at two (2) or more targeted pharmacies and written by
one (1) or more prescribers.
The prescriptions were filled at one (1) or more targeted pharmacies and
written by one (1) or more targeted prescribers.
(v) The prescriptions were filled at two (2)
or more pharmacies and written during three (3) or more emergency room
Pharmacy lock-in procedures shall
(a) A determination to place an
enrollee who has been referred as appropriate or potentially appropriate for
the lock-in program on lock-in status shall be made by the TennCare Pharmacy
Director or designee after the enrollee's relevant pharmacy claims data has
been reviewed by clinical staff.
(b) Any enrollee determined to be appropriate
for the lock-in program shall be notified by the Bureau or the MCC prior to the
imposition of lock-in status. The notice shall include a brief explanation of
the lock-in program, the reason for the determination to place the enrollee on
lock-in status, the date the lock-in will become effective, and the information
necessary for the enrollee to appeal the decision of the Bureau, pursuant to
(c) If an
enrollee fails to appeal placement in the lock-in program or an appeal is not
resolved in his favor, the enrollee will be provided TennCare pharmacy services
only at the lock-in provider to which the enrollee is assigned.
Lock-in provider selection. A
pharmacy will qualify for and may be selected by the enrollee as a lock-in
provider only if it meets all the following criteria:
(a) It is enrolled in the TennCare Pharmacy
(b) It is within the State
(c) It is a
full-service pharmacy that carries all medications normally carried by
(d) It is not a mail
order or specialty pharmacy;
is not a targeted pharmacy;
is a single pharmacy location at a specific address. A chain pharmacy may be
selected but only the specific named location may be used, not multiple
locations or outlets of the chain; and
(g) It is in proximity to the enrollee's
residence, which must be the current address on file with the Bureau.
After twelve (12) months a
member may request a change of lock-in provider once each year. Additional
changes are limited to the following reasons:
(a) The member has moved and his new address
is at least fifteen (15) miles from the lock-in pharmacy and he has updated his
address with the Bureau.
member's lock-in pharmacy has permanently closed.
(c) The member's lock-in pharmacy has
voluntarily dismissed the enrollee from its practice and has notified the
Bureau and the PBM.
(d) The Bureau
may, at its sole discretion, determine that there is a compelling need to
change the member's lock-in pharmacy.
Review of lock-in status. The Bureau or
the MCC shall periodically review the claims information of members on lock-in
status to determine the need for continued lock-in or escalation to prior
Lock-in status will be
discontinued if the Bureau determines that a member has met all of the
following criteria for at least six (6) consecutive months:
1. Has not paid cash for any controlled
substance prescriptions covered by TennCare.
2. Has not received any narcotic medications
while on buprenorphine-containing products for addiction.
3. Has received TennCare reimbursed
controlled substance prescriptions from only one (1) provider.
4. Has received TennCare reimbursed
prescriptions from only one (1) pharmacy.
(b) If a member is removed from lock-in
status, the Bureau or the MCC will monitor the member for changes in
utilization patterns and return him to lock-in status if appropriate.
Prior approval status.
(a) A member against whom criminal process
alleging TennCare fraud has been issued or who has been convicted of TennCare
fraud shall automatically be placed on prior approval status.
Lock-in status shall be escalated to
prior approval status if a member on lock-in status meets three (3) of the
following criteria over a 90 day period:
Has paid cash for three (3) or more controlled substance prescriptions covered
2. Has filled
prescriptions for controlled substances at two (2) or more
3. Has received
controlled substance prescriptions from two (2) or more prescribers.
4. Has received a narcotic prescription while
receiving buprenorphine-containing products for addiction.
(c) A member who has been treated in a
hospital emergency department for an overdose of a controlled substance (as
identified in the most recently available TennCare data) or an illicit
substance identified by toxicology shall automatically be placed on prior
Emergency pharmacy services may be obtained with a TennCare or MCC override of
a member's lock-in status. The PBM has clinical staff available at all times to
respond to emergency situations. The PBM must verify that a genuine emergency
exists, such as documented proof from the lock-in pharmacy that it is
temporarily out of stock of a needed medication. A lock-in override will not be
provided simply because a pharmacy is closed for the day unless a true medical