D.C. Mun. Regs. tit. 29, r. 29-2710
Reimbursement by the Department shall be restricted to only those drugs supplied from manufacturers that have a signed a national rebate agreement or an approved existing agreement, as specified in § 1927(a) of Title XIX of the Social Security Act (42 USC § 1396r-8(a)).
To be reimbursable, all prescriptions shall comply with District and federal laws and regulations for legal prescriptions. The District of Columbia will provide reimbursement for covered outpatient drugs consistent with prior authorization and other requirements under § 1927 of the Social Security Act.
To 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:
To be reimbursable, a prescription for a controlled substance ordered by a licensed prescriber shall contain the prescription requirements set forth in § 2710.3 and include the following additional information:
The reimbursement methods for brand name drugs and multiple source drugs, set forth under §§ 2708 and 2709 of this chapter, shall apply to the following claims, as appropriate :
Except for 340B of the Public Health Service Act (340B) contract pharmacies, federally approved 340B covered entity pharmacies that include Medicaid claims in the 340B Drug Pricing Program shall be reimbursed in accordance with §§ 2710.7 or 2710.8, as applicable, plus the professional dispensing fee of eleven dollars and fifteen cents ($11.15).
The submitted ingredient cost for drugs purchased through the Federal Public Health Service's 340B Drug Pricing Program shall mean the 340B acquisition cost, and shall be reimbursed no higher than the 340B ceiling p rice as published. 340B covered entity pharmacies shall include the National Council for Prescription Drug Program (NCPDP) indicator on each claim for drugs purchased through the 340B program.
Drugs purchased outside of the 340B program shall be submitted without the NCPDP 340B claim indicator described in § 2710.7, and shall be reimbursed using the methodology described in §§ 2708 and 2709, as applicable, plus up to the established professional dispensing fee of eleven dollars and fifteen cents ($11.15). All applicable Federal and District Supplemental rebate s shall be applied to claims submitted without the NCPDP 340B claim indicator.
Drugs acquired through the 340B drug pricing program and dispensed by 340B contract pharmacies are not covered. DHCF shall not reimburse prescription claims submitted by 340B contract pharmacies.
340B contract pharmacies shall exclude Medicaid claims from the 340B Drug Pricing Programs.
Drugs 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 provides coverage to persons who are dually eligible for excluded or otherwise restricted classes of drugs to the same extent that it provides coverage to all Medicaid beneficiaries.
Nursing facility pharmacies shall be reimbursed for an additional supply of covered medications when dispensed for use by a beneficiary residing in a long-term care facility during a short- term medically approved trip away from the facility.
Nursing facility pharmacies' reimbursement for prescribed drugs for patients in their care shall not include the following prescription drugs and items which have been included in the Medicaid reimbursement rates for nursing facilities:
D.C. Mun. Regs. tit. 29, r. 29-2710