{"data":{"id":"us-dc/d.c.-code-31-3875.02","jurisdiction":"us-dc","citation":"D.C. Code § 31-3875.02","heading":"Prior authorization requirements and restrictions.","body":"(a)\n(1)\nA utilization review entity may only require prior authorization for a covered health care service based on a determination of medical necessity for different care or that the proposed care is experimental or investigational in nature.\n(2)\nA utilization review entity may not require prior authorization:\n(A)\nBased solely on the cost of a covered health care service; provided, that:\n(i)\nNot Funded.\n(ii)\nNot Funded.\n(B)\nFor the provision of medication assisted treatment; or\n(C)\nFor pre-hospital transportation or for the provision of emergency health care services, including emergency health care services to screen and stabilize an enrollee.\n\n(b)\nA utilization review entity shall:\n(1)\nPost its current prior authorization requirements and restrictions, including formulary (\"prior authorization requirements\"), on its website, in a manner accessible to the general public without the need to create an account;\n(2)\nEmail or provide a hard copy of the prior authorization requirements to an enrollee, representative, or health care provider upon request by telephone or in writing; and\n(3)\nProvide information on its prior authorization requirements, upon request, to an enrollee, representative, or health care provider over the telephone.\n\n(c)\nPrior authorization requirements shall:\n(1)\nBe described in detail and easily understandable language;\n(2)\nInclude any written clinical criteria;\n(3)\nInclude a comprehensive listing of all drugs that require prior authorization; and\n(4)\nInclude the process for submitting, and standards for considering, including evidence-based guidelines, where possible, requests for:\n(A)\nPrior authorization approval;\n(B)\nReauthorization of a prior grant of approval; and\n(C)\nAn appeal of an adverse determination.\n\n(d)\nIf a utilization review entity intends to amend or replace its prior authorization requirements, any changes to the requirements shall not be effective until the utilization review entity's website has been updated to reflect the new requirements.","path":["Title 31. Insurance and Securities.","Chapter 38F. Prior Authorization by a Utilization Review Entity."],"source_url":"https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.02","current_through":"2026-08-20 (D.C. Law 26-175)","vintage":"","retrieved_at":"2026-08-29T05:44:07Z","sha256":"118731a8be64ba0b31030d1610627212400083ce3620e6bcb265648600493998","source_id":"us-dc","stale":false,"prev":"us-dc/d.c.-code-31-3875.01","next":"us-dc/d.c.-code-31-3875.03"},"notice":"GroundRules: Original legal text. Not legal advice."}