California’s Division of Workers’ Compensation (DWC) proposed significant changes to the Pharmaceutical Fee Schedule. The proposals would bring pharmaceutical reimbursement calculations for workers’ comp into line with revisions to Medi-Cal’s payment system, on which the Pharmacy Fee Schedule is based.

If approved, the proposed changes will be effective January 1, 2019. The DWC will accept public comments via their online forum until Monday, October 8.

Medi-Cal Changes

According to a recent DWC Newsline, Medi-Cal is currently implementing revisions to its payment methodology with the approval of the Centers for Medicare and Medicaid Services (CMS).

More information about the CMS-approved Medi-Cal changes is available on the California Department of Health Care Services (DHCS)’s Pharmacy Reimbursement Project web page.

DHCS must implement Medi-Cal’s pharmaceutical payment methodology, per federal legal mandates. In contrast, the DWC seeks advance public input before initiating the formal rulemaking process required by California Labor Code Section 5307.1. Among the changes to the calculations for workers’ comp pharmaceuticals:

• The drug dispensing fee will no longer be $7.25. Instead, the minimum dispensing fee will be $10.05, except for pharmacies listed by Medi-Cal as eligible for a $13.20 dispensing fee.
• Physicians dispensing drugs from a physician’s office will no longer receive a dispensing fee.
• The Average Wholesale Price (AWP) minus 17% will no longer be the benchmark for drug ingredient payments. Payment for drug ingredients will be the lowest of:

• National Drug Acquisition Cost (NADAC), or Wholesale Acquisition Cost (WAC) if no NADAC price exists
• The Federal Upper Limit
• The Maximum Allowable Ingredient Cost (MAIC)
• The providers’ Usual and Customary Charge

Those interested may read the proposed regulations and submit their comments on the DWC online forum for the pharmaceutical fee schedule, or mail comments to:

Division of Workers' Compensation
P.O. Box 420603
San Francisco, CA 94142
Attn: DWC forums

As always, we’ll keep our readers up to date on any further developments regarding California workers’ comp fee schedules.

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