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Warning: The DWC's Pharmacy Fee Schedule Is Not Always Accurate

September 25, 2014 by Catherine Montgomery

Every Wednesday the DWC updates the reimbursement amounts listed in the DWC’s Workers’ compensation pharmacy fee schedule - Simple prescription (Pharmacy Fee Schedule). Each Wednesday the changes to the Pharmacy Fee Schedule include:

  • New NDC numbers with reimbursements
  • New reimbursement amounts for existing NDC numbers
  • Deleting existing NDC numbers and reimbursements

While the Pharmacy Fee Schedule requires a date of service to calculate the reimbursement for an NDC number, the Pharmacy Fee Schedule only returns the correct reimbursements for new and existing NDC numbers. The DWC’s  Pharmacy Fee Schedule does not store reimbursement information for deleted NDC numbers.

For previously valid NDC numbers which were subsequently deleted by a weekly update, the Pharmacy Fee Schedule incorrectly states “No record matches the NDC number with a price date on or before xx/xx/xxxx.”  However, those deleted NDC numbers remain valid and reimbursable for their prior effective dates of service. Below see an example of a deleted NDC number with this incorrect message.

In July, the Pharmacy Fee Schedule listed NDC number 76420052401 with a reimbursement of $342.79 for a single unit, and on 8/6/2014 the Pharmacy Fee Schedule deleted this NDC number.  Yet, entering this NDC number into the DWC Pharmacy Fee Schedule with a date of service of 7/10/2014 results in an incorrect message stating: “No record matches the NDC number with a price date on or before 07/10/2014.”

fee schedule

The DaisyBill OMFS Calculator stores legacy reimbursement data for all NDC numbers going back to March 2007. For the same NDC number 76420052401 and same date of service 7/10/2014, DaisyBill’s OMFS Calculator correctly returns the following reimbursement information:

  • Base Maximum Fee: $342.79 for a single unit.
  • Effective Date: 01/01/2014
  • Ground Rules: Dispensing fee of $7.25 due per § 9789.40 (b)

Upon entering the same NDC number 76420052401 with a new date of service that falls after the DWC’s weekly update deleted the NDC number from the Pharmacy Fee Schedule, the DaisyBill OMFS Calculator returns a message indicating an invalid NDC number along with the date the NDC number expired.

The DaisyBill OMFS Calculator always uses the correct NDC reimbursement amount for past dates of service.

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