Section 29-2708. REIMBURSEMENT FOR MULTIPLE SOURCE DRUGS

 

2708.1   The allowable cost for multiple source drugs designated by the Centers for Medicare and Medicaid Services (CMS) and included in its Medicaid Drug Rebate Program (“CMS listings”) shall be the lower of the following:

 

(a) The Federal Upper Limit (FUL) for multiple source drugs other than those brand names for which a prescriber has certified in writing as “Medically Necessary” or “Brand Necessary”; or 

 

(b) The Maximum Allowable Cost (MAC) established pursuant to § 2708.2 and 2708.3.

 

2708.2     The MAC may be established for any drug, including generics when two (2) or more  A-rated therapeutically equivalent, multiple course drugs with a significant cost exist.

 

2708.3  The MAC for a drug shall be determined by:

 

 (a) Using comparable drug prices obtained from multiple nationally     recognized comprehensive data sources including, but not limited to,    pharmacy providers, wholesalers, drug file vendors, and pharmaceutical    manufacturers; and

 

(b) Reviewing the average wholesale price (AWP) and the wholesale acquisition cost (WAC), when available, or any current equivalent pricing benchmark, and applying the necessary multipliers to ensure reasonable access by providers to the drug at or below the MAC rate.    

 

2708.4      The CMS upper limit for a drug price shall not apply if a physician certifies in his

 or her own handwriting that a specific brand is medically necessary for a

 particular patient.

 

2708.5 The handwritten phrase “Medically Necessary” or “Brand Necessary” shall appear on the face of the prescription form.  If the prescription is for a nursing facility beneficiary, the handwritten phrase “Medically Necessary” or “Brand Necessary” shall be documented on the physician’s order that is maintained as part of the beneficiaries’ medical record.

 

2708.6 Neither a dual line prescription, check off-box on the prescription form, nor check off-box on the physician’s orders and plan of care shall satisfy the certification requirement.

2708.7 A generic drug may also be considered for MAC pricing if there are two (2) or more therapeutically equivalent, multiple source drugs with a price difference.  The MAC shall be based on drug status (including non rebatable, rebatable, obsolete, and therapeutic equivalency ratings), marketplace availability, and cost.  The MAC shall be based on drug prices obtained from nationally recognized comprehensive data files maintained by a vendor under contract with the DHCF.

 

2708.8 DHCF shall supplement the CMS listing by adding drugs and their prices which meet the following requirements:

(a) The formulation of the drug approved by the FDA has been evaluated as therapeutically equivalent in the most current edition of its publication, Approved Drug Products with Therapeutic Equivalence Evaluations (including supplements or in successor publications); and

 

(b) At least two (2) suppliers list the drug (which has been classified by the FDA as category “A” in its publication, Approved Drug Products with Therapeutic Equivalence Evaluations (including supplements or in successor publications)) based on listing of drugs which are locally available.

 

2708.9A pharmacy provider may identify MAC rates by visiting the District’s Pharmacy Benefits Management website at www.dcpbm.com

 

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, 2304 (March 23, 2012).