Section 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.dcpbm.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 Section 1927(d)(2) of Title XIX of the Social Security Act (42 U.S.C. § 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 U.S. Food and Drug Administration (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 Section 1927(a) of Title XIX of the Social Security Act (42 U.S.C. § 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) Weight loss;

(e) Fertility;

(f) Cosmetics;

(g) Non-prescription cough and cold;

(h) Non-prescription vitamin and mineral products;

(i) Erectile dysfunction; and

(j) Medicare Part D drugs for dual eligibles entitled to receive Medicare benefits under Medicare Part A or B.

 

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.)).

source

Notice of Final Rulemaking published at 59 DCR 2298, 2303 (March 23, 2012).