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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 29-2712. PHARMACY LOCK-IN PROGRAM
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2712.1 DHCF, along with the District of Columbia Drug Utilization Review Board (DUR Board), shall implement a Pharmacy Lock-In Program to safeguard the appropriate use of medications when an individual enrolled in the District of Columbia Medicaid Fee-for-Service Program misuses drugs in excess of the customary dosage for the proper treatment of the given diagnosis, or misuses multiple drugs in a manner that can be medically harmful. Beneficiaries listed in §2712.11 shall be exempt from the Pharmacy Lock-In Program.
2712.2 DHCF shall use the drug utilization guidelines established by the DUR Board in support of the restriction. The DUR Board guidelines shall require a monthly report from the Medicaid Management Information System to determine when a beneficiary may be at risk of exceeding the customarily prescribed dosages or utilization. The report shall identify beneficiaries who meet criteria, such as:
(a) Greater than three (3) controlled substance prescriptions per month;
(b) Greater than three (3) prescribers for controlled substances within the last ninety (90) days;
(c) Greater than ten (10) prescriptions per month; or
(d) Three (3) or more pharmacies used per month.
2712.3 At least fifteen (15) days prior to the effective date of the restriction, DHCF shall notify the Medicaid beneficiary in writing of the following:
(a)DHCF proposes to designate him or her as a restricted Medicaid beneficiary;
(b)The reason for the restriction;
(c)The effective date and duration of the restriction;
(d) The beneficiary’s right to a hearing if he or she disagrees with the designation and procedures for requesting a hearing.
2712.4 The Medicaid beneficiary shall have fifteen (15) days from the date of the notice described in §2712.3 to file a request for a hearing with the OAH.
2712.5 If the Medicaid beneficiary requests a hearing, no further action shall be taken on the restriction designation until OAH issues a final decision.
2712.6 A restriction may be required for a reasonable amount of time, not to exceed twelve (12) months, without a review by the DUR Board. Subsequent restrictions shall not be imposed until after the review has concluded.
2712.7 DHCF shall ensure that when a lock-in has been imposed, the beneficiary shall continue to have reasonable access to prescription services of adequate quality.
2712.8 When a restriction is imposed upon a beneficiary, the beneficiary may choose the pharmacy of his or her choice, based upon a list of three (3) pharmacy providers DHCF identifies.
2712.9 When a beneficiary fails to request a hearing with OAH or fails to select a designated pharmacy after a decision has been OAH renders upholding the restriction within the specified time period, DHCF, on behalf of that beneficiary, shall designate a pharmacy for pharmacy services and send a letter to the beneficiary indicating the designated pharmacy
2712.10 Restrictions shall not apply in situations where emergency services are furnished to a beneficiary.
2712.11Beneficiaries in skilled nursing facilities, long term care facilities, and intermediate care facility for people with developmental disabilities/intellectual disabilities (ICF/IDD) shall not be subject to the Pharmacy Lock-In Program.
2712.12 If a beneficiary, who is enrolled in the Medicaid Managed Care
Organization (MCO) who is also required to participate in its Pharmacy Lock-In Program, subsequently becomes enrolled in the Medicaid Fee-For-Service Program, that beneficiary shall be automatically enrolled in the Medicaid Fee-For-Service Pharmacy Lock-In Program. The lock-in shall remain in force for a period not to exceed the length of the initial lock-in period first imposed by the MCO or twelve (12) months, whichever is less.