Frequently Asked Questions
§ 9789.40 Pharmacy
The Department of Workers’ Compensation maintains the Official Medical Fee Schedule (OMFS), which consists of seven separate parts. Each of the seven parts of the OMFS have a fee schedule and associated billing requirements.
For Pharmaceuticals, Section 9789.40 of the Pharmacy Regulation provides explicit instructions for calculating reimbursements: “The maximum reasonable fee for pharmaceuticals and pharmacy services rendered after January 1, 2004 is 100 percent of the fee reimbursement prescribed in the relevant Medi-Cal payment system, including the Medi-Cal professional fee for dispensing.”
To determine the correct reimbursement for physician-dispensed pharmaceuticals for dates of service as of the most recent Wednesday, use the DWC calculator: Workers’ Compensation pharmacy fee schedule - Simple prescription. Every Wednesday afternoon, the DWC updates and replaces the reimbursements listed in the pharmacy fee schedule.
The Pharmacy fee schedule amount is 100% of the Medi-Cal rate PLUS the dispensing fee of $7.25. The dispensing fee is required per NDC number for each separate date of service. The $7.25 dispensing fee is per dispensed drug; NOT per dispensed bottle of pills.
For more information, refer to the regulations linked below.
California Workers’ Comp Regulations
- California DIR Official Medical Fee Schedule
- Physician Fee Schedule Regulations Regulations § 9789.13.3
- Pharmaceutical Fee Schedule Regulations § Section 9789.40
For the easiest way to keep up with California fee schedules and rule changes, sign up for the DaisyBill Calculator. Click below for a FREE three day trial and start easy calculations today.
Was this article helpful?
DaisyBill is a trusted authority on workers’ comp billing. Thousands of work comp professionals attend our webinars and state agencies and professional organizations turn to us for our expertise. We created this blog to help everyone involved in workers’ compensation; sharing news, tips, and data of interest to the community.
Drop us a line with any news you would like us to share or any issue that concerns you.