D.C. Mun. Regs. tit. 29 § 2706

Current through Register Vol. 71, No. 21, May 24, 2024

Rule 29-2706 - LIMITATIONS AND REQUIREMENTS FOR CERTAIN SERVICES

2706.1

All claims submitted by participating providers shall only be reimbursed if they meet relevant quantity/day supply and refill limitations established by DHCF and are available in the on- line provider manual at www.dc-pbm.com.

2706.2

Prior authorization shall be required from the DHCF designated Pharmacy Benefit Manager (PBM) for the following medications:

(a) Any drug listed as non-preferred on the District's Medicaid Preferred Drug List;

(b) Any drug requiring medication therapy management; and

(c) Any drug requiring closer utilization monitoring.

2706.3

The drugs or classes of drugs listed in § 1927(d)(2) of Title XIX of the Social Security Act ( 42 USC § 1396r-8(d)(2) ) shall be excluded from coverage unless specifically placed, either individually or by drug class, on the Medicaid Preferred Drug List of prior authorized drugs based on FDA-approved indications. The following categories of medications shall be excluded from the Medicaid outpatient pharmacy benefit:

(a) A drug which has been issued a "less than effective" ("LTE") rating by the FDA or a drug that is "identical, related or similar" to an LTE drug;

(b) A drug that has reached the termination date established by the drug manufacturer;

(c) A drug that the drug manufacturer has not entered into or has not complied with a rebate agreement for in accordance with § 1927(a) of Title XIX of the Social Security Act ( 42 USC § 1396r-8(a) ), unless DHCF reviewed and determined that it shall be in the best interest of a Medicaid beneficiary to make a payment for the non-rebated drug;

(d) Investigational drugs;

(e) Over-the-counter drugs provided by nursing home pharmacies;

(f) Weight loss;

(g) Fertility;

(h) Non-prescription cough and cold;

(i) Non-prescription vitamin and mineral products;

(j) Agents when used for the treatment of sexual or erectile dysfunction except for limited medical uses as required by federal law; and

(k) Agents when used for cosmetic purposes or hair growth except when the District has determined that use to be medically necessary.

D.C. Mun. Regs. Tit. 29, § 2706

Notice of Final Rulemaking published at 59 DCR 2298, 2303 (March 23, 2012); amended by Final Rulemaking published at 65 DCR 7824 (7/27/2018)

Authority: The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02 (2006 Repl. & 2011 Supp.)) and section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2008 Repl.)).