2706. LIMITATIONS AND REQUIREMENTS FOR CERTAIN SERVICES

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.dc-pbm.com. 2706.2 Prior authorization shall be required from the DHCF designated Pharmacy Benefit Manager (PBM) for the following medications: Any drug listed as non-preferred on the District’s Medicaid Preferred Drug List; Any drug requiring medication therapy management; and Any drug requiring closer utilization monitoring. The drugs or classes of drugs listed in § 1927(d)(2) of Title XIX of the Social Security Act (42 USC § 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 FDA-approved indications. The following categories of medications shall be excluded from the Medicaid outpatient pharmacy benefit: 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; 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 § 1927(a) of Title XIX of the Social Security Act (42 USC § 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) Investigational drugs; (e) Over-the-counter drugs provided by nursing home pharmacies; (f) Weight loss; (g) Fertility; (h) Non-prescription cough and cold; (i) Non-prescription vitamin and mineral products; (j) Agents when used for the treatment of sexual or erectile dysfunction except for limited medical uses as required by federal law; and (k) Agents when used for cosmetic purposes or hair growth except when the District has determined that use to be medically necessary. SOURCE: Final Rulemaking published at 59 DCR 2298, 2300 (March 23, 2012); as amended by Final Rulemaking published at 65 DCR 7837 (July 27, 2018). District of Columbia Municipal Regulations Public Welfare 29 DCMR § 2706