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
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