D.C. Mun. Regs. tit. 29, r. 29-2705

Current through Register Vol. 71, No. 44, November 1, 2024

Rule 29-2705 - THREE (3) DAY TEMPORARY SUPPLY

2705.1

If the prescription claim is rejected by Medicaid, due to a Prior Authorization requirement, and is otherwise valid, the provider shall provide the beneficiary with a three (3) day temporary supply, unless one (1) of the following exceptions to the three (3) day supply rule is present:

(a) The attempt to refill is too early;

(b) The rejection is due to an error that only the provider can correct;

(c) There are clinical issues that must be resolved;

(d) The prescription is for a barbiturate;

(e) The prescription is for a benzodiazepine;

(f) The prescription is for a maintenance narcotic medication;

(g) The individual is not eligible for Medicaid; or

(h) There would be a medical danger, in the provider's judgment, if a temporary supply is dispensed.

2705.2

If the beneficiary is presenting a new prescription, the provider may use discretion to determine whether there is a potential emergency to warrant a three (3) day supply.

2705.3

Providers shall not ask beneficiaries to pay for the three (3) day supply.

2705.4

Providers shall be reimbursed for the three (3) day supply and the standard dispensing fee by the Medicaid Program.

2705.5

Beneficiaries who are denied a three (3) day supply of medicine may contact the call center operated by DHCF's pharmacy benefit manager or request a hearing by contacting the Office of Administrative Hearings (OAH) or the Office of the Health Care Ombudsman if they believe their request for medication has been wrongfully denied, reduced, or not acted upon promptly.

D.C. Mun. Regs. tit. 29, r. 29-2705

Notice of Final Rulemaking published at 59 DCR 2298, 2302 (March 23, 2012)

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.)).