1. (a) The maximum reasonable fee for pharmaceuticals and pharmacy services rendered after January 1, 2004, and prior to July 1, 2025, is 100% of the reimbursement prescribed in the relevant Medi-Cal payment system data file “NDC lowest prices 2019-02-20” posted 03/08/2019, including the Medi-Cal professional fee for dispensing of $7.25 or $8.00 if the patient is in a skilled nursing facility or in an intermediate care facility. The data file will be made available on the Division of Workers' Compensation's Official Medical Fee Schedule Internet Website or upon request to the Administrative Director at:

   DIVISION OF WORKERS' COMPENSATION

   (ATTENTION: OMFS -- PHARMACY)

   P.O. BOX 420603

   SAN FRANCISCO, CA 94142.

2. (b) For a pharmacy service or drug that is not covered by a Medi-Cal payment system, the maximum reasonable fee paid shall not exceed the drug cost portion of the fee determined in accordance with this subdivision, plus $7.25 professional fee for dispensing or $8.00 if the patient is in a skilled nursing facility or in an intermediate care facility. The maximum fee shall include only a single professional dispensing fee for dispensing for each dispensing of a drug.

   1. (1) If the National Drug Code for the drug product as dispensed is not in the Medi-Cal database, and the National Drug Code for the underlying drug product from the original labeler appears in the Medi-Cal database, then the maximum fee shall be the drug cost portion of the reimbursement allowed pursuant to section 14105.45 of the Welfare and Institutions Code using the National Drug Code for the underlying drug product from the original labeler as it appears in the Medi-Cal database, calculated on a per unit basis, plus the professional fee allowed by subdivision (b) of this section.
   2. (2) If the National Drug Code for the drug product as dispensed is not in the Medi-Cal database and the National Drug Code for the underlying drug product from the original labeler is not in the Medi-Cal database, then the maximum fee shall be 83 percent of the average wholesale price of the lowest priced therapeutically equivalent drug, calculated on a per unit basis, plus the professional fee allowed by subdivision (b) of this section.

3. (c) For purposes of this section:

   1. (1) “Therapeutically equivalent drugs” means drugs that have been assigned the same Therapeutic Equivalent Code starting with the letter “A” in the Food and Drug Administration's publication “Approved Drug Products with Therapeutic Equivalence Evaluations” (“Orange Book”.) The Orange Book may be accessed through the Food and Drug Administration's website.
   2. (2) “National Drug Code for the underlying drug product from the original labeler” means the National Drug Code of the drug product actually utilized by the repackager in producing the repackaged product.
4. (d) This section applies to pharmaceuticals dispensed and pharmaceutical services rendered prior to July 1, 2025.
5. (e) The Medi-Cal data file “NDC lowest prices 2019-02-20” posted 03/08/2019 and the Table 2024 compounding fee/sterility fee table posted on the internet website of the Division of Workers' Compensation will remain in effect for pharmaceuticals dispensed prior to July 1, 2025.

Note: Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 4603.2 and 5307.1, Labor Code.

History

1. New section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No. 2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 1-2-2004 order, including redesignation of existing section as subsection (a) and new subsection (b), transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).

3. Amendment of subsections (a) and (b) and new subsections (b)(1)-(d) filed 2-28-2007; operative 2-28-2007. Submitted to OAL for printing purposes only pursuant to Government Code section 11343.8, as exempt from the APA and OAL review pursuant to Government Code section 11340.9(g) (Register 2007, No. 9).

4. Amendment of section heading and subsections (a) and (c)(1), repealer of former subsection (d) and new subsections (d)-(e) filed 12-11-2024; operative 7-1-2025. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2024, No. 50).