28 Tex. Admin. Code § 134.503 - Pharmacy Fee Guideline
(a) Applicability
of this section is as follows:
(1) This
section applies to the reimbursement of prescription drugs and nonprescription
drugs or over-the-counter medications as those terms are defined in §
134.500 of this title
(Definitions) for outpatient use in the Texas workers' compensation system,
which includes claims:
(A) subject to a
certified workers' compensation health care network as defined in §
134.500 of this title;
(B) not subject to a certified workers'
compensation health care network; and
(C) subject to Labor Code §
504.053(b)(2).
(2) This section does not apply to
parenteral drugs.
(b)
For coding, billing, reporting, and reimbursement of prescription drugs and
nonprescription drugs or over-the-counter medications, Texas workers'
compensation system participants must comply with Chapters 133 and 134 of this
title (General Medical Provisions and Benefits--Guidelines for Medical
Services, Charges, and Payments, respectively).
(c) The insurance carrier must reimburse the
health care provider or pharmacy processing agent for prescription drugs the
lesser of:
(1) the fee established by the
following formulas based on the average wholesale price (AWP) as reported by a
nationally recognized pharmaceutical price guide or other publication of
pharmaceutical pricing data in effect on the day the prescription drug is
dispensed:
(A) Generic drugs: ((AWP per unit)
x (number of units) x 1.25) + $4.00 dispensing fee per prescription =
reimbursement amount;
(B)
Brand-name drugs: ((AWP per unit) x (number of units) x 1.09) + $4.00
dispensing fee per prescription = reimbursement amount;
(C) When compounding, a single compounding
fee of $15 per prescription must be added to the calculated total for either
paragraph (1)(A) or (B) of this subsection; or
(2) notwithstanding §
133.20(e)(1) of
this title (Medical Bill Submission by Health Care Provider), the amount billed
to the insurance carrier by the:
(A) health
care provider; or
(B) pharmacy
processing agent only if the health care provider has not previously billed the
insurance carrier for the prescription drug, and the pharmacy processing agent
is billing on behalf of the health care provider.
(d) Reimbursement for
nonprescription drugs or over-the-counter medications must be the retail price
of the lowest package quantity reasonably available that will fill the
prescription.
(e) Except as
provided by subsection (f) of this section, if an amount cannot be determined
under subsections (c)(1) or (d) of this section, reimbursement must be an
amount that is consistent with the criteria listed in Labor Code §
408.028(f),
including providing for reimbursement rates that are fair and reasonable. The
insurance carrier must:
(1) develop one or
more reimbursement methodologies for determining reimbursement under this
subsection;
(2) maintain in
reproducible format documentation of the insurance carrier's methodologies for
establishing an amount;
(3) apply
the reimbursement methodologies consistently among health care providers in
determining reimbursements under this subsection; and
(4) on the division's request, provide to the
division copies of such documentation.
(f) Notwithstanding the provisions of this
section, the insurance carrier may reimburse prescription medication or
services, as defined by Labor Code §
401.011(19)(E),
at a contract rate that is inconsistent with the fee guideline as long as the
contract complies with the provisions of Labor Code §
408.0281 and applicable
division rules.
(g) When the
prescribing doctor has written a prescription for a generic drug or a
prescription that does not require the use of a brand-name drug under §
134.502(a)(3) of
this title (Pharmaceutical Services), reimbursement must be as follows:
(1) the health care provider must dispense
the generic drug as prescribed, and the insurance carrier must reimburse the
fee established for the generic drug, under subsection (c) or (f) of this
section; or
(2) when an injured
employee chooses to receive a brand-name drug instead of the prescribed generic
drug, the health care provider must dispense the brand-name drug as requested
and must be reimbursed:
(A) by the insurance
carrier, the fee established for the prescribed generic drug under subsection
(c) or (f) of this section; and
(B)
by the injured employee, the cost difference between the fee established for
the generic drug in subsection (c) or (f) of this section and the fee
established for the brand-name drug under subsection (c) or (f) of this
section.
(h)
When the prescribing doctor has written a prescription for a brand-name drug
under §
134.502(a)(3) of
this title, reimbursement must be under subsection (c) or (f) of this
section.
(i) On request by the
health care provider or the division, the insurance carrier must disclose the
source of the nationally recognized pricing reference used to calculate the
reimbursement.
(j) Where any
provision of this section is determined by a court of competent jurisdiction to
be inconsistent with any statutes of this state, or to be unconstitutional, the
remaining provisions of this section remain in effect.
Notes
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