| (a) Applicability of this section is as follows:
(1) This section applies to the reimbursement of prescription
drugs and nonprescription drugs or over-the-counter medications as
those terms are defined in §134.500 of this title (Definitions)
for outpatient use in the Texas workers' compensation system, which
includes claims:
(A) subject to a certified workers' compensation health
care network as defined in §134.500 of this title;
(B) not subject to a certified workers' compensation
health care network; and
(C) subject to Labor Code §504.053(b)(2).
(2) This section does not apply to parenteral drugs.
(b) For coding, billing, reporting, and reimbursement
of prescription drugs and nonprescription drugs or over-the-counter
medications, Texas workers' compensation system participants must
comply with Chapters 133 and 134 of this title (General Medical Provisions
and Benefits--Guidelines for Medical Services, Charges, and Payments,
respectively).
(c) The insurance carrier must reimburse the health
care provider or pharmacy processing agent for prescription drugs
the lesser of:
(1) the fee established by the following formulas based
on the average wholesale price (AWP) as reported by a nationally recognized
pharmaceutical price guide or other publication of pharmaceutical
pricing data in effect on the day the prescription drug is dispensed:
(A) Generic drugs: ((AWP per unit) x (number of units)
x 1.25) + $4.00 dispensing fee per prescription = reimbursement amount;
(B) Brand-name drugs: ((AWP per unit) x (number of
units) x 1.09) + $4.00 dispensing fee per prescription = reimbursement
amount;
(C) When compounding, a single compounding fee of $15
per prescription must be added to the calculated total for either
paragraph (1)(A) or (B) of this subsection; or
(2) notwithstanding §133.20(e)(1) of this title
(Medical Bill Submission by Health Care Provider), the amount billed
to the insurance carrier by the:
(A) health care provider; or
(B) pharmacy processing agent only if the health care
provider has not previously billed the insurance carrier for the prescription
drug, and the pharmacy processing agent is billing on behalf of the
health care provider.
(d) Reimbursement for nonprescription drugs or over-the-counter
medications must be the retail price of the lowest package quantity
reasonably available that will fill the prescription.
(e) Except as provided by subsection (f) of this section,
if an amount cannot be determined under subsections (c)(1) or (d)
of this section, reimbursement must be an amount that is consistent
with the criteria listed in Labor Code §408.028(f), including
providing for reimbursement rates that are fair and reasonable. The
insurance carrier must:
(1) develop one or more reimbursement methodologies
for determining reimbursement under this subsection;
(2) maintain in reproducible format documentation of
the insurance carrier's methodologies for establishing an amount;
(3) apply the reimbursement methodologies consistently
among health care providers in determining reimbursements under this
subsection; and
(4) on the division's request, provide to the division
copies of such documentation.
(f) Notwithstanding the provisions of this section,
the insurance carrier may reimburse prescription medication or services,
as defined by Labor Code §401.011(19)(E), at a contract rate
that is inconsistent with the fee guideline as long as the contract
complies with the provisions of Labor Code §408.0281 and applicable
division rules.
(g) When the prescribing doctor has written a prescription
for a generic drug or a prescription that does not require the use
of a brand-name drug under §134.502(a)(3) of this title (Pharmaceutical
Services), reimbursement must be as follows:
(1) the health care provider must dispense the generic
drug as prescribed, and the insurance carrier must reimburse the fee
established for the generic drug, under subsection (c) or (f) of this
section; or
(2) when an injured employee chooses to receive a brand-name
drug instead of the prescribed generic drug, the health care provider
must dispense the brand-name drug as requested and must be reimbursed:
(A) by the insurance carrier, the fee established for
the prescribed generic drug under subsection (c) or (f) of this section;
and
(B) by the injured employee, the cost difference between
the fee established for the generic drug in subsection (c) or (f)
of this section and the fee established for the brand-name drug under
subsection (c) or (f) of this section.
(h) When the prescribing doctor has written a prescription
for a brand-name drug under §134.502(a)(3) of this title, reimbursement
must be under subsection (c) or (f) of this section.
(i) On request by the health care provider or the division,
the insurance carrier must disclose the source of the nationally recognized
pricing reference used to calculate the reimbursement.
(j) Where any provision of this section is determined
by a court of competent jurisdiction to be inconsistent with any statutes
of this state, or to be unconstitutional, the remaining provisions
of this section remain in effect.
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| Source Note: The provisions of this §134.503 adopted to be effective January 3, 2002, 26 TexReg 10970; amended to be effective March 14, 2004, 29 TexReg 2346; amended to be effective October 23, 2011, 36 TexReg 6949; amended to be effective November 28, 2024, 49 TexReg 9758 |
