D.C. Mun. Regs. tit. 29, r. 29-2712

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-2712 - 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:

(a) Use of drugs in excess of the customary dosage for the proper treatment of the given diagnosis; and

(b) 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:

(a) Three (3) or more controlled substance prescriptions per month;

(b) Three (3) or more prescribers for controlled substance prescriptions per month;

(c) Three (3) or more pharmacies for controlled substance prescriptions per month; or

(d) 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:

(a) Assigning the beneficiary to a single pharmacy provider;

(b) Assigning the beneficiary to a single medical provider; or

(c) 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;

(d) 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);

(e) The specific laws and regulations, with citations, supporting DHCF's intent to designate the beneficiary as a pharmacy lock-in participant;

(f) 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;

(g) 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:

(a) Beneficiaries receiving care in:

(1) Skilled nursing facilities;

(2) Long term care facilities; or

(3) Intermediate care facility for people with developmental disabilities/intellectual disabilities (ICF/IDD);

(b) Beneficiaries with an active cancer diagnosis;

(c) Beneficiaries who are homeless;

(d) Beneficiaries with a recent surgery or hospitalization;

(e) 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

(f) 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.

D.C. Mun. Regs. tit. 29, r. 29-2712

Notice of Final Rulemaking published at 59 DCR 2298, 2308 (March 23, 2012); amended by Final Rulemaking published at 70 DCR 2719 (3/3/2023)

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.).