1. (1) The department may enroll a member in the Restriction Program if the member meets one or more of the following restriction criteria within the most recent 12 months of Medicaid eligibility:

   1. (a) accesses four or more non-affiliated PCPs and specialists;
   2. (b) accesses four or more pharmacies for the purchase of abuse potential medications;
   3. (c) accesses three or more non-affiliated providers who prescribe abuse potential medications in a consecutive two-month period;
   4. (d) accesses six or more prescriptions for abuse potential medications in a consecutive two-month period;
   5. (e) accesses emergency department services for five or more non-emergent emergency department visits;
   6. (f) fills concurrent prescriptions for abuse potential medications, written by different prescribers;
   7. (g) pays cash for Medicaid-covered services; or
   8. (h) accesses concurrently prescribed abuse potential medications written by different prescribers without medical necessity or the knowledge or consent of the different prescribers.

2. (2) The department shall also consider the following when determining whether to place a member in the Restriction Program:

   1. (a) the member's diagnoses and medical necessity;
   2. (b) the member's concurrent prescribers of abuse potential medications;
   3. (c) the member's geographic location and potential of limited access to care in rural areas; and
   4. (d) the member's right to seek a second opinion.
3. (3) Once a member is found to meet or exceed restriction criteria, the department shall perform an additional review to determine if overutilization of services was the result of limited access to care or medical necessity.
4. (4) When an individual is placed in the Restriction Program, the member shall have one assigned PCP and one assigned pharmacy.

5. (5) The department may only pay claims for services provided by the assigned PCP, prescriptions written by the assigned PCP, and prescriptions filled by the assigned pharmacy unless:

   1. (a) services were provided upon referral from the assigned PCP;
   2. (b) prescribers were authorized as assigned prescribers by the assigned PCP;
   3. (c) services were provided by an emergency department;
   4. (d) services and resulting prescriptions were provided in a hospital inpatient setting;
   5. (e) services were provided by an urgent care center; or
   6. (f) services were provided by Medicaid-enrolled providers not licensed to prescribe medications, such as behavioral health counselors or physical therapists.
6. (6) Enrollment in the Restriction Program does not affect the restricted member's ability to access emergency services.

KEY: Medicaid

Date of Last Change: October 28, 2024

Notice of Continuation: August 22, 2022

Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108