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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-27. MEDICAID REIMBURSEMENT FOR FEE FOR SERVICE PHARMACY SERVICES |
Section 29-2705. THREE (3) DAY TEMPORARY SUPPLY
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2705.1If 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.
2705.2If 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.
2705.3Providers shall not ask beneficiaries to pay for the three (3) day supply.
2705.4Providers shall be reimbursed for the three (3) day supply and the standard dispensing fee by the Medicaid Program.
2705.5Beneficiaries 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.