2712. PHARMACY LOCK-IN PROGRAM

2712 PHARMACY LOCK-IN PROGRAM 2712.1 The Department of Health Care Finance (DHCF) shall implement the Pharmacy Lock-In Program established by this section to safeguard against the following types of misuse of medications by beneficiaries enrolled in the District of Columbia Medicaid Fee-for-Service (FFS) program: Use of drugs in excess of the customary dosage for the proper treatment of the given diagnosis; and Use of multiple drugs in a manner that can be medically harmful. 2712.2 DHCF shall use the drug utilization guidelines established by the DUR Board in support of the lock-in to a single pharmacy or medical provider, as outlined in further detail in section 2712.3. 2712.3 The Medicaid FFS Pharmacy Benefit Manager (PBM) shall submit a monthly report to DHCF and the DUR Board that identifies Medicaid FFS beneficiaries who, within the prior ninety (90) days, meet one (1) or more of the following criteria: Three (3) or more controlled substance prescriptions per month; Three (3) or more prescribers for controlled substance prescriptions per month; Three (3) or more pharmacies for controlled substance prescriptions per month; or Ten (10) or more prescriptions per month. 2712.4 If a beneficiary is identified as having met one (1) or more of the criteria listed in subsection 2712.1 or 2712.3, DHCF may impose a lock-in on the beneficiary by doing the following: Assigning the beneficiary to a single pharmacy provider; Assigning the beneficiary to a single medical provider; or Assigning the beneficiary to a single pharmacy provider and a single medical provider. 2712.5 At least thirty (30) days before the effective date of a lock-in, DHCF shall issue to the beneficiary a notice, consistent with the requirements at 42 CFR § 435.917, that includes the following information: (a) A statement of DHCF’s intent to designate the beneficiary as a pharmacy lock-in beneficiary; (b) The reason for the intended lock-in; (c) If DHCF intends to lock in the beneficiary to a single pharmacy provider: (1) A list of three (3) pharmacy providers from which the beneficiary may select their preferred pharmacy for the lock-in, and the deadline by which the beneficiary must make the selection; and (2) An explanation that if the beneficiary does not select a pharmacy provider from the list provided by DHCF within fifteen (15) days of DHCF’s notice, DHCF will designate the pharmacy lock-in provider; If DHCF intends to lock in the beneficiary to a single medical provider, the name of the medical provider to which the beneficiary will be locked in (which shall be the beneficiary’s primary care provider); The specific laws and regulations, with citations, supporting DHCF’s intent to designate the beneficiary as a pharmacy lock-in participant; The beneficiary’s right to a hearing if the beneficiary disagrees with the designation, the deadline by which the beneficiary must request a hearing, and the procedures for requesting a hearing; An explanation that DHCF will not implement the lock-in if the beneficiary requests a hearing within thirty (30) days of DHCF’s notice. 2712.6 When a lock-in includes assigning a beneficiary to a single pharmacy provider, the beneficiary may select their lock-in pharmacy, from the list provided by DHCF pursuant to section 2712.5(c), within fifteen (15) days of DHCF’s notice under § 2712.5. If the beneficiary does not select a lock-in pharmacy within the fifteen (15) day period, DHCF shall designate a lock-in pharmacy provider. 2712.7 The beneficiary shall have ninety (90) days from the date of the notice described in § 2712.5 to file a request for a hearing with the Office of Administrative Hearings (“OAH”). 2712.8 If the beneficiary requests a hearing within thirty (30) days from the date of the notice described in § 2712.5, no further action shall be taken by DHCF on the intended lock-in until the request for a hearing is dismissed or a final decision has been rendered by the OAH upholding the lock-in. 2712.9 If the beneficiary does not request a hearing within thirty (30) days from the date of the notice described in § 2712.5, DHCF shall impose the lock-in and send a notice to the beneficiary stating that the lock-in has become effective. The notice shall also identify the lock-in pharmacy assigned to the beneficiary. 2712.10 A lock-in imposed pursuant to § 2712.9 shall remain in effect even if the beneficiary requests a hearing thirty-one (31) to ninety (90) days from the date of the initial notice described in § 2712.5. The lock-in shall be revised or revoked, if necessary, based on the final decision issued by OAH. 2712.11 A pharmacy lock-in may be imposed for a period of time not to exceed twelve (12) months; provided, that the lock-in may be renewed or extended for subsequent periods of time each not to exceed twelve (12) months. (a) No lock-in shall be imposed without a review by the DUR Board. (b) Subsequent lock-ins for the beneficiary shall not be imposed until after a review by the DUR Board has concluded. 2712.12 DHCF shall ensure that when a lock-in has been imposed, the beneficiary will continue to have reasonable access to adequate Medicaid services. 2712.13 DHCF shall not apply a lock-in to a situation where the beneficiary uses emergency services. 2712.14 The following beneficiaries shall not be subject to a pharmacy lock-in: Beneficiaries receiving care in: Skilled nursing facilities; Long term care facilities; or Intermediate care facility for people with developmental disabilities/intellectual disabilities (ICF/IDD); Beneficiaries with an active cancer diagnosis; Beneficiaries who are homeless; Beneficiaries with a recent surgery or hospitalization; Beneficiaries who are determined to be “self-locked-in” (for the purposes of this provision, when the beneficiary receives approximately 85% of their medications from one (1) pharmacy); and Other individual beneficiaries designated by the DUR Board, on a case-by-case basis. 2712.15 Each Medicaid MCO, or its designee, shall implement a pharmacy lock-in program as comprehensive as the lock-in program outlined in this section. 2712.16 If a Medicaid FFS beneficiary subject to a pharmacy lock-in subsequently becomes enrolled in a Medicaid MCO, the beneficiary shall be automatically enrolled in the Medicaid MCO’s Pharmacy Lock-In Program. The lock-in shall remain in effect for the length of the lock-in imposed by Medicaid FFS. 2712.17 If a Medicaid MCO beneficiary subject to a pharmacy lock-in subsequently becomes enrolled in Medicaid FFS, the beneficiary shall be automatically enrolled in the Medicaid FFS’s lock-in program. The lock-in shall remain in effect for the length of the lock-in imposed by the MCO. 2712.18 If a Medicaid MCO beneficiary subject to a pharmacy lock-in subsequently becomes enrolled in another Medicaid MCO, that beneficiary shall be automatically enrolled in the new Medicaid MCO’s lock-in program. The lock-in shall remain in effect for the length of the lock-in imposed by the original Medicaid MCO. SOURCE: Notice of Final Rulemaking published at 59 DCR 2298, 2308 (March 23, 2012); as amended by Final Rulemaking published at 70 DCR 002719 (March 3, 2023). District of Columbia Municipal Regulations Public Welfare 29 DCMR § 2712