This article covers Idaho’s workers' compensation fee schedule rules for pharmacy and Durable Medical Equipment (DME).
Pharmacy
IDAPA 17.01.01.806.04 - Acceptable Charges For Medicine Provided By Pharmacies.
The following standards shall be used to determine the acceptable charge for medicine provided by pharmacies.
a. Brand/Trade Name Medicine. The standard for determining the acceptable charge for brand/trade name medicine shall be the AWP, plus a five dollar ($5) dispensing fee.
b. Generic Medicine. The standard for determining the acceptable charge for generic medicine shall be the AWP, plus an eight dollar ($8) dispensing fee.
c. Compound Medicine. The standard for determining the acceptable charge for compound medicine shall be the sum of the AWP for each drug included in the compound medicine, plus a five dollar ($5) dispensing fee and a two dollar ($2) compounding fee.
All components of the compound medicine shall be identified by their original manufacturer's NDC when submitted for reimbursement.
Payors may withhold reimbursement until the original manufacturer's NDC assigned to each component of the compound medicine is provided by the Pharmacy.
Components of a compound medicine without an NDC may require medical necessity confirmation by the treating physician prior to reimbursement.
d. Prescribed Over-the Counter Medicine. The standard for determining the acceptable charge for prescribed over-the-counter medicine filled by a Pharmacy shall be the reasonable charge plus a two dollar ($2) dispensing fee.
Durable Medical Equipment (DME)
IDAPA 17.01.01.806.05 - Acceptable Charges For Medical Services Provided By Other Providers Under The Idaho Worker's Compensation Law.
The standard for determining the acceptable charge for Providers other than physicians, Hospitals or ASCs shall be the reasonable charge.
a. Durable Medical Equipment (DME) Providers. Within the first thirty (30) days of equipment use, the Payor shall be given the option to rent or purchase DME.
Rented equipment shall be considered purchased once the rental charges exceed the purchase price, which may not exceed ten percent (10%) of the invoice cost.
If purchased, the DME shall become the property of the Claimant.
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