Section 418.10912. Billing for prescription medications.

(1) Prescription drugs may be dispensed to an injured worker by either an outpatient pharmacy or a health care organization as defined in these rules. These rules shall apply to the pharmacy dispensing the prescription drugs to an injured worker only after the pharmacy has either written or oral confirmation from the carrier that the prescriptions or supplies are covered by workers' compensation insurance.

(2)   When a generic drug exists, the generic drug shall be dispensed. When a generic drug does not exist, the brand name drug may be dispensed. A physician may only write a prescription for "DAW", or dispense as written, when the generic drug has been utilized and found to be ineffective or has caused adverse effects for the injured worker. A copy of the medical record documenting the medical necessity for the brand name drug shall be submitted to the carrier.

(3)    A bill or receipt for a prescription drug from an outpatient pharmacy, practitioner, or health care organization shall be submitted to the carrier and shall include the name, address, and social security number of the injured worker. An outpatient pharmacy shall bill the service using the NCPDP Workers’ Compensation/Property & Casualty Universal Claim Form or an invoice and shall include either the pharmacy’s NPI or NCPDP number, and the NDC of the prescription drug.

(4)   A health care organization or physician office dispensing the prescription drug shall bill the service on the CMS 1500 claim form. Procedure code 99070 shall be used to code the service and the national drug code shall be used to describe the drug.

(5)   If an injured worker has paid for a prescription drug for a covered work illness, then the worker may send a receipt showing payment along with the drug information to the carrier for reimbursement.

(6)    An outpatient pharmacy or health care organization shall include all of the following information when submitting a bill for a prescription drug to the carrier:

(a)   The brand or chemical name of the drug dispensed.

(b)     The NDC number from Red Book or Medi-Span as adopted by reference in R 418.10107.

(c)   The dosage, strength, and quantity dispensed.

(d)  The date the drug was dispensed.

(e)   The physician prescribing the drug.

(7)   A practitioner or a health care organization, other than an inpatient hospital, shall bill

WC700-G to describe the dispense fee for each generic prescription drug and WC700-B to describe the dispense fee for each brand name prescription drug. A provider will only be reimbursed for 1 dispense fee for each prescription drug in a 10-day period. A dispense fee shall not be billed with "OTC"s, over-the-counter drugs.

History: 2000 AACS; 2002 AACS; 2005 AACS; 2008 AACS; 2014 AACS.