District of Columbia

Liver damage restrictions

Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not have liver damage restrictions.

Sobriety restrictions

FFS requires a beneficiary to be screened and counseled for alcohol and substance use. Two MCOs, AmeriHealth Caritas and CareFirst Community Health Plan District of Columbia, also require screening and counseling for alcohol and substance use. Medstar Family Choice District of Columbia requires documentation of the patient’s ability to adhere to treatment and submission of office visit notes detailing alcohol and other substance use.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist. AmeriHealth Caritas requires a prescription to be written by a specialist. CareFirst Community Health Plan District of Columbia requires that if the prescriber is not a specialist, a one-time written consultation report from a specialist will be required within the past 3 months. Medstar Family Choice District of Columbia does not require prescriber restrictions.

Recommendations

• Remove sobriety and prescriber restrictions.
• Require coverage parity across the FFS and MCO program and ensure transparency regarding coverage criteria for hepatitis C medications.