Section 29-2710. CLAIMS REIMBURSEMENT REQUIREMENTS FOR PHARMACIES

 

2710.1Reimbursement by the Department shall be restricted to only those drugs supplied from manufacturers that have a signed a national agreement or an approved existing agreement, as specified in Section 1927(a) of Title XIX of the Social Security Act (42 U.S.C. § 1396r-8(a)).. 

 

2710.2All prescriptions shall comply with District, state and federal laws and regulations for legal prescriptions. 

 

2710.3To be reimbursable, all prescriptions that have been written, verbally ordered, or electronically initiated by a licensed prescriber shall contain the following information on the prescription form:

 

(a) Name and address of patient;

 

(b) Individual Prescriber’s Name and National Provider Identifier (NPI);

 

(c)Name, strength and quantity of the medication;

 

(d) Directions for use;

 

(e) Number of refills, if any;

 

(f) Indication for “brand medically necessary,” when applicable; and

 

(g) Signature and date of the prescriber.

 

2710.4To be reimbursable, prescriptions for controlled substances ordered by a licensed prescriber shall contain the prescription requirements set forth in §2710.3 and include the following additional information:

(a) The Drug Enforcement Agency (DEA) number of the licensed prescriber;

 

(b) The District of Columbia controlled substance registration number of the licensed prescriber; and

 

(c) The X-DEA number of the licensed prescriber for buprenorphine/naloxone drug preparations.

 

2710.5  Reimbursement for pharmacy claims submitted by a community or retail pharmacy provider shall be reimbursed at the lower of the following:

 

(a) The allowable cost, established pursuant to the methodology described in this chapter, as appropriate, plus a dispensing fee of four dollars and fifty cents ($4.50) per prescription; or  

 

(b) The pharmacy’s usual and customary charge to the general public.

 

  2710.6Drugs covered by Medicare for persons who are dually eligible for Medicare and Medicaid shall be billed to Medicare under the Medicare Prescription Drug Benefit- Part D.  The Medicaid program shall continue to provide coverage to persons who are dually eligible for the following excluded or otherwise restricted classes of drugs to the same extent that it provides coverage to all Medicaid beneficiaries:

 

(a) Select agents when used for weight gain: Megesterol;

 

(b) Select prescription vitamins and mineral products except prenatal vitamins and fluoride: Folic Acid, Vitamin B 12;

 

(c) Select non-prescription drugs: analgesics, antacids, and bowel diagnostic preparation kits;

 

(d) All barbiturates until January 1, 2013; and

 

(e) All benzodiazepines until January 1, 2013. 

 

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, 2306 (March 23, 2012).