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(a)The maximum allowable reimbursement (MAR) for prescription drugs shall be the lesser of: (1)The provider's usual and customary charge for the same or similar service; (2)The fees established by the following formulas based on the average wholesale price (AWP) determined by utilizing a nationally recognized pharmaceutical reimbursement system (e.g. Redbook, First Data Bank Services) in effect on the day the prescription drug is dispensed. (A)Brand name or Generic Pharmaceuticals: [(AWP per unit) x (number of units) x 1.25] + $4.00 dispensing fee = MAR; (B)A compounding fee of $30 per compound shall be added for compound drugs; or, (3)A negotiated or contract amount. (b)When the doctor has written a prescription for a generic prescription drug or a prescription that does not require the use of a brand-name drug, in accordance with rule 134.502 (a)(3), the pharmacist shall dispense and be reimbursed for the generic pharmaceutical medication. (c)Reimbursement for over the counter drugs shall be the reasonable retail value. (d)This section applies to the dispensing of all drugs except inpatient drugs and parenteral drugs. (e)The insurance carrier shall update drug and supply pricing data at least every 30 days. Upon request by the provider, the insurance carrier shall disclose the source of the AWP used.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on August 20, 2001
TRD-200104908 Susan Cory
General Counsel
Texas Workers' Compensation Commission
Earliest possible date of adoption: September 30, 2001
For further information, please call: (512) 804-4287
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