Medication Access Within Your Practice

State Fee Schedule

• Brand Prescriptions: Retail brand medications are reimbursed using the applicable AWP benchmark and professional dispensing amount.
• Generic Prescriptions: Generic medications follow the corresponding AWP-based methodology and dispensing amount.
• Payment Limitation: Final reimbursement may be limited by the applicable fee schedule, usual and customary charge, or contracted network rate.
• Alternative Pricing: Where an AWP benchmark is unavailable, an alternative pricing methodology may apply.

Sources: Alaska Administrative Code Title 8, Section 45.083(i)(1), 8 AAC 45.083(i)(2), Optum Pharmacy Resource Guide - Workers’ Compensation March 2026.

Direct Care

• Provider Selection: Alaska generally allows an injured worker to select the attending physician responsible for directing treatment, subject to applicable state requirements.

Sources: Alaska Statutes 23.30.095(a), 8 AAC 45.082, Optum Pharmacy Resource Guide - Workers’ Compensation March 2026.

Pre-Authorization

• Drug Formulary: Alaska does not impose a state closed drug formulary. Certain prescriptions may still be subject to utilization controls or payer review.

Source: Alaska Statutes 23.30.095.

OTC Restrictions

• Prescription Requirement: OTC products supplied for Workers’ Compensation treatment generally require an appropriate prescription to qualify for reimbursement.
• Pricing: Eligible OTC medications may be reimbursed according to the applicable generic pricing methodology.
• Dispensing Fee: OTC products may not qualify for a separate professional dispensing fee.

Sources: 8 AAC 45.083, Optum Pharmacy Resource Guide - Workers’ Compensation March 2026.

Topical Restrictions

• Commercial Topicals: Non-compounded topical products are evaluated using Alaska's applicable brand or generic reimbursement methodology.
• Compound Limit: Topical compounds are subject to a maximum reimbursement amount for a 30-day supply, subject to prorating.
• Quantity Controls: Certain topical medications may be reviewed against applicable quantity limitations.

Sources: 8 AAC 45.083, Optum Pharmacy Resource Guide - Workers’ Compensation March 2026.

Compound Restrictions

• Ingredient Detail: Compound claims must identify individual ingredients and applicable NDC and quantity information.
• Pricing Methodology: Components are evaluated using the applicable manufacturer pricing benchmark.
• Compounding Fee: A prescribed compound may be subject to a single applicable compounding fee rather than multiple fees for individual components.

Sources: Alaska Administrative Code Title 8, Section 45.083(i)(3), Optum Pharmacy Resource Guide - Workers’ Compensation March 2026.

Timelines

• Payer Payment Period: Covered medical bills are subject to the applicable payment period following receipt by the employer or insurer.
• Payment Disputes: When payment is denied or disputed, applicable parties must receive the required notice explaining the basis for the decision.
• Employee Protection: Injured workers are protected from direct collection of covered charges during qualifying billing or medical-necessity disputes.
• Dispute Resolution: Pharmacy providers may use the applicable administrative process to challenge reimbursement determinations.

Sources: Alaska Statutes 23.30.095, AS 23.30.110, 8 AAC 45.082(d), 8 AAC 45.070.

Pricing Source

• Pricing Databases: National prescription pricing databases, including Red Book and Medi-Span, may serve as applicable reimbursement references.

Sources: 8 AAC 45.082, 8 AAC 45.083, Alaska Department of Labor and Workforce Development Official Administrative Bulletins.

State Fee Schedule

• Brand Medications: Brand prescriptions are reimbursed using the applicable AWP percentage and established dispensing fee.
• Generic Medications: Generic prescriptions follow the corresponding AWP percentage and dispensing fee.
• Generic Selection: Applicable guidelines encourage use of the lowest-cost generic option when available.

Sources: Industrial Commission of Arizona 2026 Physicians’ and Pharmaceutical Fee Schedule Guidelines, effective May 1, 2026 through April 30, 2027.

Direct Care

• Provider Selection: Injured workers generally have provider-selection rights, although the employer or carrier may direct the initial visit under applicable circumstances.
• Pharmacy Selection: An injured worker may select a pharmacy subject to applicable Workers’ Compensation requirements.

Source: Arizona Revised Statutes 23-908(B).

Pre-Authorization

• Formulary Requirements: Medications covered under the applicable ODG guidelines generally do not require pre-authorization.
• Optional Approval: Providers may seek advance approval where appropriate to establish payer authorization before treatment or services are provided.

Source: Ariz. Rev. Stat. 23-1044, May 1, 2026 Fee Update.

OTC Restrictions

• Eligible OTC Products: Qualifying OTC medications may be reimbursed at applicable retail pricing.
• Topical Limits: Certain OTC creams, lotions, and patches are subject to maximum reimbursement amounts for a 30-day supply, with prorating where applicable.

Topical Restrictions

• Commercial Products: Non-compounded topical prescriptions are reimbursed under the applicable Arizona pricing methodology.
• Compound Limit: Topical compounds may be reimbursed up to the established maximum for a 30-day supply, subject to prorating.

Compound Restrictions

• Ingredient-Level Billing: Compound prescriptions must identify each ingredient separately with the required NDC and quantity information.
• Ingredient Valuation: Components are priced using the applicable Arizona fee schedule methodology.
• Professional Fee: The applicable dispensing fee is applied to the overall compound transaction rather than separately to each component.

Source: ICA 2026 Pharmaceutical Fee Schedule Ground Rules.

Timelines

• Claim Submission: Pharmacy providers must submit properly coded claims within the applicable billing period following dispensing.
• Employee Protection: Injured workers are protected from direct collection of covered claim charges during qualifying payment or medical-necessity disputes.
• Payment Disputes: Pharmacy providers may use the applicable appeal process when challenging an adverse reimbursement determination.

Sources: Arizona Revised Statutes 23-1062.01, ICA Medical Resource Office Dispute Guidelines.

Pricing Source

• Pricing Reference: Medi-Span pricing data may be used as an applicable medication pricing reference.

Sources: A.R.S. Title 23, Industrial Commission of Arizona Official Year Selector Directories.

State Fee Schedule

• Brand and Generic Drugs: Arkansas uses an Average Wholesale Price (AWP) calculation plus a $5.13 professional dispensing fee for both brand-name and generic outpatient medications.
• Lower-of Payment Review: Pharmacy claims may be evaluated against the state fee schedule, the pharmacy's submitted usual and customary (U&C) price, or an applicable contracted MCO/PPO rate. The lowest applicable amount determines reimbursement.
• Uniform Dispensing Fee: A $5.13 dispensing fee applies to both brand and generic medications.

Sources: Arkansas Workers' Compensation Commission Rule 30, Medical Cost Containment Program Fee Schedule, Optum Workers' Compensation Pharmacy Resource Guide, March 2026.

Direct Care

• Employer/Carrier Direction: Arkansas follows an employer-choice model. The employer or workers' compensation carrier may select the initial treating physician or authorized medical facility.

Sources: Arkansas Code Annotated Section 11-9-514, AWCC Cost Containment Division Directives.

Pre-Authorization

• Formulary Requirements: Arkansas workers' compensation claims are subject to a closed drug formulary. Certain excluded medications and higher-risk opioid therapies may require advance approval from the adjuster before dispensing.

Source: AWCC Rule 099.41, Workers' Compensation Drug Formulary.

OTC Restrictions

• Prescription Required: OTC products dispensed for a workers' compensation injury generally require a valid prescription from the authorized treating provider to qualify for reimbursement.
• OTC Pricing: When properly prescribed, retail OTC medications are reimbursed according to the pharmacy's submitted U&C price or applicable contracted rate rather than receiving an additional manual markup.

Sources: Arkansas Workers' Compensation Commission Rule 30 Section I, Optum Workers' Compensation Pharmacy Resource Guide, March 2026.

Topical Restrictions

• Standard Pricing: Commercially manufactured topical medications, including prescription creams, gels, and ointments, are generally subject to the state's standard AWP-based reimbursement methodology.
• Utilization Controls: High-cost topical medications may be subject to quantity, units, and days' supply edits based on applicable utilization protocols.

Source: AWCC Rule 099.41 Formularies.

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must identify individual ingredients separately, including applicable quantities and NDC information.
• Ingredient Pricing: Each eligible ingredient is evaluated using the applicable AWP-based fee schedule calculation.
• Single Dispensing Fee: Multiple dispensing fees cannot be added for individual compound ingredients. One $5.13 dispensing fee applies to the completed compound transaction.

Sources: AWCC Rule 30 Section I, Optum Workers' Compensation Pharmacy Resource Guide, March 2026.

Timelines

• Bill Submission: Pharmacy claims should be submitted electronically and within the applicable workers' compensation billing timeframe following dispensing.
• Payer Response: Carriers, self-insured employers, and TPAs must process properly submitted claims within applicable prompt-payment requirements.
• Employee Protection: Injured workers generally should not be balance-billed for covered workers' compensation pharmacy services while a claim or payment dispute is being addressed.
• Payment Disputes: Pharmacies disputing an underpayment or adverse reimbursement determination may pursue the applicable AWCC administrative dispute process.

Sources: Arkansas Code Annotated Section 11-9-513, AWCC Rule 30 Section II.

Pricing Source

• National pricing databases, including Red Book and Medi-Span AWP data, may be used in determining applicable drug pricing.

Sources: AWCC Rules of the Commission Directory, Arkansas Administrative Code Title 099.

State Fee Schedule

• Brand and Generic Pricing: California bases outpatient pharmacy reimbursement on the DWC weekly pharmaceutical data file rather than AWP.
• Dispensing Fee: The applicable ingredient rate is supplemented by a $10.05 or $13.20 dispensing fee depending on the pharmacy's applicable tier.
• Lowest-Cost Methodology: When standard pricing information is unavailable, reimbursement may be determined using applicable alternatives such as NADAC, WAC, FUL, or MAIC.
• AWP Exclusion: AWP is not used as the ingredient pricing benchmark for California outpatient workers' compensation pharmacy claims.

Sources: California Labor Code Section 5307.1, CCR Title 8 Section 9789.40, DWC Pharmaceutical Fee Schedule directives.

Direct Care

• Treatment Direction: California permits the employer to direct medical treatment under applicable workers' compensation rules, including the initial period following injury reporting.

Sources: California Labor Code Sections 4600 and 4616, CCR Title 8 Section 9767.1.

Pre-Authorization

• MTUS Formulary: Prescription medications are governed by the Medical Treatment Utilization Schedule (MTUS) drug formulary. Exempt medications may qualify for streamlined processing, while non-exempt medications can require additional review.

Source: California Labor Code Section 5307.27, DWC MTUS Formulary.

OTC Restrictions

• Prescription Requirement: OTC products generally require a valid prescription from the authorized treating provider to qualify for workers' compensation reimbursement.
• Reimbursement Basis: Prescribed OTC products are generally subject to the pharmacy's U&C price or an applicable contracted network rate.

Sources: California Labor Code Section 5307.1, CCR Title 8 Section 9789.40, applicable California pharmacy pricing guidance.

Topical Restrictions

• Standard Pricing: Manufactured topical medications are evaluated under California's applicable DWC pharmaceutical pricing methodology.
• Quantity Controls: Certain higher-cost topical products may be reviewed for appropriate quantity, units, and days' supply under utilization guidelines.

Sources: CCR Title 8 Section 9789.40, MTUS Drug Formulary Guidelines.

Compound Restrictions

• Detailed Ingredient Billing: Compounded prescriptions should identify each ingredient separately, including the applicable quantity and NDC.
• Ingredient-Based Pricing: Eligible compound ingredients are priced according to applicable manufacturer and NDC data.
• One Dispensing Fee: Pharmacies cannot apply multiple dispensing fees to individual compound ingredients. A single applicable dispensing fee is used for the prescription.

Sources: CCR Title 8 Section 9789.40.3, Optum Workers' Compensation Pharmacy Guide.

Timelines

• Payer Response: California generally requires carriers and other responsible payers to act on properly submitted pharmacy bills within 45 days.
• Employee Protection: Injured workers should not be balance-billed for covered pharmacy services during an active workers' compensation payment or medical-necessity dispute.
• Second Bill Review: A pharmacy disputing reimbursement may request a Second Bill Review within the applicable timeframe.
• Independent Bill Review: If the dispute remains unresolved, the provider may pursue Independent Bill Review under applicable California requirements.

Sources: California Labor Code Sections 4603.2 and 4603.6, CCR Title 8 Section 9792.5.5.

Pricing Source

• California DWC's official weekly pharmaceutical fee data and applicable NPI data files serve as primary pricing resources.

Sources: California Labor Code Title 8, Division of Workers' Compensation official directories.

State Fee Schedule

• Standard Pricing: Brand and generic medications are generally calculated using AWP plus a $4.00 dispensing fee.
• AWP Alternative: When an applicable AWP is unavailable, WAC multiplied by 1.20 may be used as the alternative pricing basis.
• Retail Pharmacy Requirements: Certain controlled medications and specified therapeutic categories must be dispensed through licensed pharmacies under applicable Colorado rules.
• Repackaged Products: Repackaged or relabeled medications may be priced using the original manufacturer's NDC rather than the repackager's pricing information.

Sources: Colorado DWC Rules of Procedure, Rules 18-6(1) and 18-6(2), Optum Workers' Compensation Pharmacy Resource Guide.

Direct Care

• Pharmacy Choice: Colorado generally allows an injured worker to use a licensed retail pharmacy for an authorized workers' compensation prescription, subject to applicable fee schedule requirements.

Sources: Colorado DWC Rules of Procedure, Rules 16 and 18-6, C.R.S. 8-43-404.

Pre-Authorization

• Medical Treatment Guidelines: Colorado uses its Medical Treatment Guidelines formulary. Certain high-dose narcotic therapies, compounds, and specialized medications may require prospective authorization.

Source: 7 CCR 1101-3 Rule 17.

OTC Restrictions

• Prescription Requirement: OTC medications generally require a valid prescription from the Authorized Treating Provider documenting medical necessity.
• Pricing: Prescribed OTC products are generally priced using the same applicable methodology as other covered pharmacy medications, including AWP + $4.00 or the applicable WAC-based calculation.
• Dispensing Fee: A qualifying OTC prescription may receive the applicable $4.00 dispensing fee.

Sources: Colorado DWC Rules of Procedure, Rules 18-6(1) and 18-6(2), Optum Pharmacy Resource Guide.

Topical Restrictions

• Prior Authorization: Certain brand-name or prescription-strength topical products may require advance authorization when a substantially less expensive therapeutic alternative is available.
• OTC Topical Limits: Applicable Colorado rules establish reimbursement limits for certain non-prescription topical products.
• Repackaged Products: Repackaged topical medications may be evaluated using the original manufacturer's NDC and applicable pricing benchmark.

Sources: Colorado DWC Rules of Procedure, Rules 18-6(1) and 18-6(4), Optum Workers' Compensation Pharmacy Resource Guide.

Compound Restrictions

• Ingredient Breakdown: Each ingredient in a compound should be separately identified with the applicable quantity and NDC.
• Compound Categories: Certain topical compounds are subject to Colorado's designated Z-code reimbursement categories and corresponding maximums.
• Overall Limit: Compounds outside applicable topical Z-code categories may be subject to additional reimbursement ceilings.
• Compounding Fee: Eligible retail pharmacies may receive one $10.00 compounding fee per prescription.

Sources: Colorado DWC Rules of Procedure, Rule 18-6, Optum Workers' Comp Pharmacy Resource Guide.

Timelines

• Submission Deadline: Pharmacy bills generally must be submitted within 120 days of the date of service.
• Electronic Billing: Providers meeting applicable billing-volume thresholds may be required to submit claims electronically using HIPAA-standard formats.
• Receipt Confirmation: Electronic claims may receive an acknowledgment within the applicable processing period.
• Payer Response: Clean claims are generally subject to a 30-day payment, reduction, or denial period.
• Late Payment: Applicable unpaid balances may be subject to statutory interest.
• Disputes: Providers may first request reconsideration from the payer and then pursue the applicable DOWC fee dispute process.

Sources: Colorado DWC Rules of Procedure, Rules 16 and 18-11.

Pricing Source

• Medi-Span and Red Book may be used as applicable national drug pricing references.

Sources: Colorado DWC Rules of Procedure, Rules 16 and 18-6, Colorado Medical Fee Schedule updates.

State Fee Schedule

• Brand Drugs: Brand medications are priced using AWP multiplied by 0.681, plus a $3.29 dispensing fee.
• Generic Drugs: Generic medications use AWP multiplied by 0.62, plus a $4.10 dispensing fee.
• Lower-of Methodology: Final reimbursement may be based on the lowest applicable amount among the pharmacy's U&C charge, contracted PBM rate, or state fee schedule calculation.

Sources: 19 Delaware Code Section 2322B, 19 Delaware Administrative Code 1341 Section 4.14, Optum Workers' Compensation Pharmacy Resource Guide.

Direct Care

• Pharmacy Direction: Delaware workers' compensation rules permit employers or carriers to direct pharmacy services through an applicable PBM network or designated pharmacy arrangement.

Sources: Boone v. Syab Services/Capitol Nursing, 2013 WL 3777153, Delaware Supreme Court; 19 Delaware Code Section 2322.

Pre-Authorization

• Utilization Requirements: State-specific treatment guidelines and fee schedule requirements apply. Certain non-preferred medications may require prospective approval.

Source: Delaware Code Title 19 Section 2322, applicable fee schedule rules.

OTC Restrictions

• Prescription Requirement: OTC medications generally require a valid prescription from an authorized treating provider before they qualify for workers' compensation reimbursement.
• Brand OTC Pricing: Prescribed brand OTC medications follow the applicable AWP × 0.681 calculation plus a $3.29 dispensing fee.
• Generic OTC Pricing: Prescribed generic OTC medications follow the AWP × 0.62 calculation plus a $4.10 dispensing fee.

Sources: 19 Delaware Code Section 2322B, 19 Delaware Administrative Code 1341 Section 4.14, Optum Workers' Compensation Pharmacy Resource Guide.

Topical Restrictions

• Standard Pricing: Manufactured topical medications are generally processed under the same brand or generic reimbursement methodology as other legend drugs.
• Missing NDC Data: When original manufacturer NDC information is unavailable, the payer or billing network may use an appropriate equivalent NDC and corresponding pricing data.
• Utilization Requirements: Topical products may still be subject to applicable Preferred Drug List and prior authorization requirements.

Sources: 19 Delaware Code Section 2322B, 19 Delaware Administrative Code 1341 Section 4.14, Optum Workers' Compensation Pharmacy Resource Guide.

Compound Restrictions

• Ingredient-Level Review: Compounded prescriptions should be itemized by individual ingredient with the applicable NDC and AWP information.
• Compounding Fee: Delaware allows an applicable $10.00 professional compounding fee per compound.
• Compound Maximum: Certain topical compounds may be subject to a $200.00 maximum for a 30-day supply, prorated where applicable.

Sources: 19 Delaware Administrative Code 1341 Section 4.14, Optum Workers' Compensation Pharmacy Resource Guide.

Timelines

• Claim Submission: Electronic pharmacy claims may transmit at the point of sale. Manual or paper claims are subject to applicable filing deadlines.
• Payer Response: Clean pharmacy claims generally fall under a 30-day payment, reduction, or denial requirement.
• Late Payment: Applicable overdue balances may be subject to statutory interest.
• Reconsideration: Pharmacies may submit an appeal or reconsideration request within the applicable timeframe after receiving an adverse payment determination.
• Administrative Review: Unresolved disputes may be brought before the Delaware Industrial Accident Board under applicable workers' compensation procedures.

Sources: 19 Delaware Code Sections 2322F(h) and 2361, 19 Delaware Administrative Code 1341 Section 5.0.

Pricing Source

• Red Book and Medi-Span may be used as national drug pricing references.

Sources: 19 Delaware Code Section 2322B, 19 Delaware Administrative Code 1341 Section 4.14, Delaware Department of Labor HCPS Preferred Drug List Guidelines.

About Clinic Meds

Clinic Meds helps workers' compensation pharmacies navigate state-specific reimbursement requirements, formulary rules, billing considerations, and pharmacy fee schedules. Check the applicable state requirements before submitting or disputing a claim.

State Fee Schedule

• Updated Pricing Model: Connecticut's July 2026 pharmacy reimbursement changes moved away from the prior AWP-plus model.
• Brand Medications: Brand drugs are calculated using 20% of AWP with a $5.00 dispensing fee.
• Generic Medications: Generic drugs are calculated using 80% of AWP with an $8.00 dispensing fee.
• Missing NDC Information: When original manufacturer information is unavailable, the applicable payer or billing network may use an appropriate equivalent NDC and associated pricing data.

Sources: Connecticut Workers' Compensation Commission Practitioner Fee Schedule, Section III(C), Optum Workers' Compensation Pharmacy Resource Guide.

Direct Care

• Managed Care Plans: When an employer uses a state-approved Managed Care Plan, treatment may be directed through the plan's participating provider network.
• No MCP: Where an approved MCP is not in place, the employer may still direct the initial treatment under applicable Connecticut workers' compensation rules.

Sources: Connecticut General Statutes Sections 31-279-10 and 31-294d, Connecticut Workers' Compensation Commission regulations.

Pre-Authorization

• Utilization Review: Connecticut applies applicable formulary and utilization requirements. Certain non-preferred medications may require prospective certification before reimbursement.

Source: Conn. Gen. Stat. Section 31-294d, WCC Guidelines.

OTC Restrictions

• Prescription Requirement: OTC medications generally require a valid prescription from the Authorized Treating Provider for workers' compensation reimbursement.
• Brand OTC Pricing: Prescribed brand OTC products follow the applicable AWP-based calculation with a $5.00 dispensing fee.
• Generic OTC Pricing: Prescribed generic OTC products follow the applicable AWP-based calculation with an $8.00 dispensing fee.

Sources: Connecticut Workers' Compensation Commission Practitioner Fee Schedule, Section III(C), Optum Workers' Compensation Pharmacy Resource Guide.

Topical Restrictions

• No Specific Topical Cap: Connecticut does not publish a separate statewide reimbursement cap specifically for manufactured topical medications.
• Standard Pricing: Topical prescriptions are generally processed under the applicable brand or generic pharmacy pricing methodology.
• Utilization Review: Higher-cost or non-standard topical therapies may be subject to prior authorization or utilization review.

Sources: Connecticut Workers' Compensation Commission Administrative Rules, applicable pharmacy reimbursement guidance.

Compound Restrictions

• Limited State-Specific Guidance: Connecticut does not publish a separate comprehensive fee schedule specifically governing retail compounded prescriptions.
• Ingredient Pricing: PBM networks may evaluate compound ingredients individually using applicable NDC and AWP data.
• Prior Authorization: Compounded medications may require advance authorization because of their non-formulary status.

Sources: Connecticut Workers' Compensation Commission Practitioner Fee Schedule Guidelines, Section III(C), Optum Workers' Compensation Pharmacy Resource Guide.

Timelines

• Electronic Claims: Pharmacy claims submitted electronically through a PBM may be processed through real-time transactions.
• Paper Claims: Back-billed or paper pharmacy claims are subject to applicable statutory submission deadlines.
• Payer Response: Electronic claims may be subject to a 30-day payment or denial period, while paper claims may follow a different statutory timeframe.
• Late Payment: Qualifying late payments may accrue statutory interest.
• Dispute Process: Pharmacies may first pursue payer or PBM reconsideration and, when unresolved, seek the appropriate Connecticut Workers' Compensation Commission hearing or administrative remedy.

Sources: Connecticut General Statutes Sections 31-294d and 31-280-3, Connecticut Workers' Compensation Commission administrative regulations.

Pricing Source

• Red Book and Medi-Span are commonly used national drug pricing references.

Sources: Connecticut Workers' Compensation Commission Memorandum No. 2000-03, Conn. Agencies Regs. 31-280-3, Optum Workers' Compensation Pharmacy Resource Guide.

State Fee Schedule

• Brand-Name Pricing: Florida reimburses brand-name outpatient medications at AWP plus a $4.18 professional dispensing fee.
• Generic Pricing: Generic medications follow the same AWP + $4.18 reimbursement formula.
• Lower-of Pricing Rule: Final reimbursement is subject to the lowest applicable amount among the state fee schedule calculation, the pharmacy's submitted Usual and Customary (U&C) price, or a contracted PBM rate.
• Retail Pharmacy Processing: Prescriptions filled through licensed retail pharmacies are processed under the standard state reimbursement methodology when the medication is authorized and related to the accepted injury.

Sources: Florida Statutes 440.13(12)(c); Florida Administrative Code Rule 69L-7.740; Optum Workers' Compensation Pharmacy Resource Guide.

Direct Care

• Pharmacy Choice: Florida does not permit employers or carriers to require an injured worker to use a specific retail pharmacy or PBM network. The employee may select any licensed pharmacy or pharmacist for prescribed medications.

Sources: Florida Statutes 440.13(3)(j); Publix Super Markets, Inc. v. Department of Financial Services (Fla. 1st DCA, 2026).

Pre-Authorization

• Open Formulary: Standard prescriptions generally follow the AWP + $4.18 reimbursement structure unless a separate PBM contract applies.

Source: Fla. Stat. 440.13; DWC Reimbursement Rules.

OTC Restrictions

• Prescription Requirement: OTC medications and supplies generally require a valid written prescription from an authorized treating provider to qualify for workers' compensation reimbursement.
• OTC Pricing: Properly prescribed OTC products are reimbursed using the AWP + $4.18 methodology.
• Dispensing Fee: A $4.18 professional dispensing fee remains applicable to eligible prescribed OTC medications.
• Formulary Review: PBM systems may review OTC products against the applicable formulary. Common products may process at the point of sale, while specialized or higher-cost items can require additional review.

Sources: Florida Statutes 440.13(12)(c); Florida Administrative Code Rule 69L-7.740; Florida Workers' Compensation Health Care Provider Reimbursement Manual.

Topical Restrictions

• Standard Topicals: Commercially manufactured prescription creams, gels, ointments, and sprays generally follow the AWP + $4.18 reimbursement formula.
• OTC Topical Limits: Certain OTC creams, ointments, and gels may be limited to $31.21 per 30-day supply, prorated as applicable.
• OTC Patches: Certain non-prescription therapeutic patches may be limited to $72.83 per 30-day supply, with prorating based on the supply dispensed.
• Prescription Topicals: Manufactured prescription-only topicals generally remain under the standard AWP + $4.18 methodology when applicable authorization requirements are satisfied.

Sources: Florida Statutes 440.13(12)(c); Florida Administrative Code Rule 69L-7.740; Optum Workers' Compensation Pharmacy Resource Guide.

Compound Restrictions

• Ingredient-Level Billing: Custom compounds must be itemized by individual ingredient, with reimbursement determined using the applicable NDC and AWP for each eligible component.
• Compounding Fee: One $4.18 professional fee applies to the compound prescription.
• Topical Compound Cap: Certain topical compounds are subject to a $200.00 maximum for a 30-day supply, prorated according to the quantity dispensed.
• PBM Authorization: Compound prescriptions may be blocked at point of sale and require carrier authorization when a commercially available therapeutic alternative exists.

Sources: Florida Statutes 440.13(12)(c); Florida Administrative Code Rule 69L-7.740; Optum Workers' Compensation Pharmacy Resource Guide.

Timelines

• Claim Submission: Florida does not establish a specific statutory deadline for initial retail pharmacy billing, although electronic point-of-sale submission through PBM systems is standard.
• Payer Response: Carriers and TPAs generally have 45 calendar days after receiving a properly submitted pharmacy bill to pay, reduce, or deny the claim.
• Late Payment: Qualifying unpaid balances may be subject to statutory interest and administrative penalties.
• Dispute Process: Pharmacies may challenge a payment reduction or denial through the Florida Division of Workers' Compensation and pursue further administrative review when necessary.

Sources: Florida Statutes 440.13(7); Florida Administrative Code Chapter 69L-31.

Pricing Source

• Medi-Span

Sources: Florida Statutes 440.13(12)(c); Florida Administrative Code Rules 69L-7.020 and 69L-7.740.

State Fee Schedule

• Brand Medications: Brand-name drugs are reimbursed using AWP plus a $4.36 dispensing fee.
• Generic Medications: Generic drugs use AWP plus a $6.53 dispensing fee.
• Lower-of Rule: The final allowed amount is generally the lowest applicable value among the state maximum allowable reimbursement, the pharmacy's U&C charge, and an applicable PBM contract rate.
• Retail Pharmacy Fees: Licensed retail pharmacies may receive the applicable professional dispensing fee, while physician-dispensed medications follow separate reimbursement requirements.

Sources: Georgia State Board of Workers' Compensation Medical Fee Schedule, Section IV; O.C.G.A. § 34-9-200.

Direct Care

• Network Direction: Employers and carriers may direct pharmacy services through an established PBM or pharmacy network. When such a network applies, workers may be required to use participating retail pharmacies or authorized mail-order services.

Sources: O.C.G.A. § 34-9-200; Georgia House Bill 1119; Georgia State Board of Workers' Compensation Rule 201.

Pre-Authorization

• Formulary Processing: Georgia generally uses an open formulary structure, with PBM controls applying to certain compounds and brand-name products when a generic equivalent is available.

Source: Ga. Code Ann. § 34-9-205; SBWC Rules.

OTC Restrictions

• Prescription Requirement: OTC medications generally require a signed prescription from the Authorized Treating Physician to qualify for workers' compensation reimbursement.
• OTC Pricing: Prescribed OTC products are reimbursed using the applicable original manufacturer AWP plus 50% methodology.
• Dispensing Fee: The standard brand or generic dispensing fees do not apply to OTC products. The percentage markup serves as the applicable allowance.
• Invoice Review: Bill review systems may request supporting wholesale documentation to validate the submitted reimbursement amount.

Sources: Georgia State Board of Workers' Compensation Medical Fee Schedule, Section IV; Georgia State Board Topical Amendment Guidelines.

Topical Restrictions

• Category-Based Limits: Georgia applies specific reimbursement ceilings to topical medications based on their active ingredients:
  • Category I, GA0801: Up to $80.00 per 30-day supply for qualifying single-agent anti-inflammatory or local anesthetic products.
  • Category II, GA0802: Up to $160.00 per 30-day supply for qualifying combinations of anti-inflammatory and local anesthetic agents.
  • Category III, GA0803: Up to $240.00 per 30-day supply for other qualifying topical formulations.
• Overall Ceiling: No applicable topical prescription line may exceed $240.00 for a 30-day supply.
• Prorated Limits: Maximums are adjusted according to the actual supply or quantity dispensed.
• OTC Topicals: Prescribed OTC topical products may be subject to both the AWP-based calculation and applicable category limits.
• Refills: Recurring topical refills require a new or updated prescription under applicable processing requirements.

Sources: Georgia State Board of Workers' Compensation Medical Fee Schedule, Section IV, Subsection C; Optum Workers' Compensation Pharmacy Resource Guide.

Compound Restrictions

• Compounding Pharmacy Requirement: Multi-ingredient compounds must be prepared and billed through a licensed compounding pharmacy.
• Ingredient Pricing: Each active ingredient must be separately identified with its quantity and NDC. Eligible ingredients are evaluated using the applicable AWP-based formula.
• NDC Requirement: Components without a valid FDA-recognized NDC are generally non-reimbursable.
• Active Ingredient Limit: Reimbursement applies to compounds containing no more than three active ingredients.
• Compounding Fee: A $20.00 compounding fee may apply per qualifying prescription.

Sources: Georgia State Board of Workers' Compensation Medical Fee Schedule, Section IV; Georgia State Board of Pharmacy Rules and Regulations, Chapter 480-11.

Timelines

• Submission Deadline: Retail pharmacies generally have one year from dispensing to submit an initial workers' compensation pharmacy claim.
• Payer Response: Carriers, TPAs, or PBM administrators generally have 30 calendar days to pay, reduce, or deny a properly submitted claim.
• Late Payment: Delayed undisputed payments may result in additional statutory penalties and interest.
• First-Level Dispute: Pharmacy payment disputes may initially be submitted to the payer or PBM within the applicable appeal period.
• State Review: Unresolved disputes may proceed through the Georgia State Board of Workers' Compensation using the applicable filing process.

Sources: O.C.G.A. § 34-9-203(c); Georgia State Board of Workers' Compensation Rule 203.

Pricing Source

• Medi-Span

Sources: Georgia State Board of Workers' Compensation Fee Schedule Guidelines; O.C.G.A. § 34-9-200; Optum Workers' Compensation Pharmacy Resource Guide.

State Fee Schedule

• Brand Drugs: Brand-name medications are reimbursed at AWP multiplied by 1.40.
• Generic Drugs: Generic medications follow the same AWP × 1.40 calculation.
• Dispensing Fee: Retail pharmacies do not receive a separate professional dispensing fee under this methodology.
• Lower-of Rule: Reimbursement is based on the lowest applicable amount among the AWP × 1.40 calculation, the pharmacy's U&C price, or a lower contracted PBM rate.
• Compounds: Compound ingredients are evaluated individually using applicable AWP data and valid manufacturer NDC information.
• GET: Eligible Hawaii General Excise Tax may be reimbursed separately when properly itemized.

Sources: HRS 386-21.7(a), (b), and (c); HAR 12-15-55; Hawaii DLIR Workers' Compensation Supplemental Medical Fee Schedule Guidelines.

Direct Care

• Employee Choice: Hawaii generally allows injured employees to select their treating physician. Employers and carriers have limited authority to direct initial medical care.
• Limited Exceptions: Employer-selected care may apply in emergency circumstances or when the employee declines to choose a physician.

Sources: HRS 386-21; HAR 12-15-55.

Pre-Authorization

• Initial Treatment: Pre-authorization and treatment plans generally are not required for the first 15 treatments during the initial 60-day period.
• Extended Treatment: Continued care beyond 60 days or 15 visits requires an appropriate treatment plan submitted to the employer or carrier in advance.
• Treatment Plan Period: Approved plans may cover up to 120 days and 15 treatments per authorization period.

Source: Hawaii Revised Statutes Chapter 386; HAR § 12-15-32.

OTC Restrictions

• Prescription Requirement: OTC medications require a signed prescription from the attending physician and must be related to the accepted work injury to qualify for reimbursement.
• Pricing: Properly prescribed OTC products follow the AWP × 1.40 ceiling.
• Lower-of Review: Final payment is limited to the lower of the applicable fee schedule amount or the pharmacy's U&C price.
• Dispensing Fee: No separate professional dispensing fee applies.
• GET: Applicable GET may be separately itemized and reimbursed.

Sources: HRS 386-21 and 386-21.7; HAR 12-15-55.

Topical Restrictions

• Manufactured Topicals: Commercially manufactured creams, ointments, gels, and patches generally follow the AWP × 1.40 methodology.
• Source NDC Requirement: Pricing should be based on the original manufacturer's NDC and corresponding AWP information.
• Missing NDC Information: Claims lacking required original manufacturer information may be subject to rejection or additional review.
• OTC Topical Caps: Certain non-prescription topical products are subject to specific supply-based limits:
  • Creams and Lotions: Up to $30.00 for a 30-day supply.
  • Therapeutic Patches: Up to $75.00 for a 30-day supply.
• Proration: Applicable OTC topical limits are adjusted based on the quantity or supply dispensed.
• GET: Qualifying GET may be separately reimbursed.

Sources: HRS 386-21(c) and 386-21.7(a), (d); HAR 12-15-55; Hawaii House Bill 1648 guidelines.

Compound Restrictions

• Ingredient-Level Calculation: Custom compounds are reimbursed based on the individual eligible ingredients, with each component evaluated using AWP × 1.40.
• NDC Documentation: Each active ingredient must include its quantity and applicable manufacturer NDC.
• Source NDC Requirement: Repackaged or secondary NDCs may require documentation of the original manufacturer's source NDC.
• Compounding Fee: No separate professional compounding or handling fee is added to the reimbursement.
• GET: Applicable GET may be separately itemized.

Sources: HRS 386-21.7(a) and (c); HAR 12-15-55; Hawaii DLIR Workers' Compensation Supplemental Medical Fee Schedule Guidelines.

Timelines

• Submission Deadline: Pharmacy claims generally must be submitted within two years of the dispensing date.
• Payer Response: Carriers, TPAs, or PBM administrators generally have 60 calendar days after receiving a properly formatted bill to pay or issue a written denial.
• Late Payment: Qualifying unpaid balances may accrue interest at 1% per month.
• Initial Dispute: Pharmacies disputing an adjustment or denial may submit a formal bill dispute to the Hawaii Department of Labor and Industrial Relations.
• Mediation: Following a dispute request, the parties may enter the applicable negotiation period before formal administrative review.
• Administrative Review: Unresolved disputes may proceed to formal review by the DLIR Director under the applicable process.

Sources: HAR 12-15-94(b) and (c); HRS 386-21.

Pricing Source

• Red Book

Sources: HRS 386-21.7(b) and (c); HAR 12-15-55; Hawaii DLIR Medical Fee Schedule Guidelines.

State Fee Schedule

• Brand Medications: Brand-name drugs are reimbursed at AWP plus a $5.00 dispensing fee.
• Generic Medications: Generic drugs use AWP plus an $8.00 dispensing fee.
• Lower-of Rule: The applicable reimbursement is the lowest amount among the state fee schedule calculation, the pharmacy's U&C charge, or an applicable PBM contract rate.
• Therapeutic Alternative Limit: When a substantially less expensive therapeutic equivalent is available, reimbursement may be limited to no more than 30% above the cost of the lower-priced equivalent.

Sources: IDAPA 17.01.01.803.04(a), (b), and (f); Idaho Industrial Commission Medical Fee Schedule Guidelines; Optum Workers' Compensation Pharmacy Fee Schedule and PBM Adjudication Network Contract Rates.

Direct Care

• Employer Direction: Idaho permits employers and carriers to direct an injured worker's primary medical care within the applicable workers' compensation network.
• Pharmacy Network: Pharmacy selection may remain subject to the carrier's contracted PBM network requirements.

Sources: Idaho Code 72-432(1) and (7); Idaho Industrial Commission Benefit Administration Guidelines; IDAPA 17.01.01.803.

Pre-Authorization

• ODG Formulary: Idaho uses the Official Disability Guidelines (ODG) Drug Formulary. Medications designated for authorization may be blocked at point of sale until approval is obtained.

Source: Idaho Code 72-432; Industrial Commission Rules.

OTC Restrictions

• Prescription Requirement: OTC medications generally require a prescription from the attending physician connecting the treatment to the accepted work injury.
• Pricing: Prescribed OTC products generally follow the applicable AWP-based pharmacy pricing formula with a $4.00 professional dispensing fee.
• Lower-of Rule: Reimbursement is limited to the lower applicable amount between the fee schedule calculation and the pharmacy's U&C price.
• Therapeutic Equivalent Cap: When a lower-cost therapeutic equivalent is available, the reimbursement may be limited to 30% above that alternative's baseline cost.
• Source NDC: Original manufacturer NDC information should be submitted. Missing or repackager-only information may trigger additional review.

Sources: IDAPA 17.01.01.803.04(d) and (f); Idaho Industrial Commission Medical Fee Schedule Guidelines.

Topical Restrictions

• Standard Pricing: Manufactured topical medications generally follow the applicable AWP + $5.00 brand or AWP + $8.00 generic methodology.
• Original NDC: Repackaged products may need to be priced using the original manufacturer's NDC and AWP information.
• Missing Source Data: Claims without sufficient original manufacturer information may be held pending documentation.
• Therapeutic Equivalent Rule: A topical product with a lower-cost equivalent may be subject to the 30% above-equivalent cost limitation.
• Refill Review: Recurring topical refills may require renewed documentation or authorization to establish continued medical necessity.

Sources: IDAPA 17.01.01.803.04; Idaho Industrial Commission Medical Fee Schedule Guidelines.

Compound Restrictions

• Ingredient-Level Pricing: Compounded medications are evaluated ingredient by ingredient. Eligible reimbursement includes the applicable AWP for each valid active ingredient.
• Fees: The applicable calculation may include a $5.00 dispensing fee and $2.00 compounding fee.
• NDC Requirement: Each compound ingredient should include a valid manufacturer NDC. Ingredients without required NDC information may be non-reimbursable.
• Source NDC Review: Repackaged ingredients may require original manufacturer information before payment is released.

Sources: IDAPA 17.01.01.803.04; Idaho Industrial Commission Medical Fee Schedule Guidelines.

Timelines

• Submission Deadline: Pharmacy claims generally must be submitted within one year of the dispensing date.
• Initial Payer Response: Carriers, TPAs, or PBM administrators generally have 30 days after receiving a properly submitted claim to pay or issue an objection or request for clarification.
• Clarification Period: If additional information is requested, the pharmacy generally has 30 days to respond, followed by an additional payer review period.
• Late Payment: Eligible unpaid balances may accrue interest at the applicable statutory rate.
• Formal Dispute: A pharmacy challenging a final objection may pursue formal medical dispute resolution through the Idaho Industrial Commission.
• Mediation: The parties may mutually use an IIC-facilitated mediation process before proceeding to a formal administrative hearing.

Sources: IDAPA 17.01.01.803.04; Idaho Judicial Rules of Practice and Procedure, Rule 19.

Pricing Source

• Red Book

Sources: IDAPA 17.01.01.803.04; Idaho Industrial Commission Medical Services Reference Guidelines.

State Fee Schedule

• Retail Pharmacy Pricing: Brand and generic medications dispensed through licensed retail pharmacies are generally reimbursed at 100% of the pharmacy's actual and reasonable U&C charge, subject to applicable requirements.
• Direct Dispensing: Medications dispensed outside a licensed retail pharmacy may follow a separate AWP + $4.18 reimbursement formula.
• AWP Data: Applicable AWP information is determined using the drug's NDC and published pricing data.
• Repackaged Products: Repackaged medications may be priced using the underlying medication and original labeler's NDC information.

Sources: 820 ILCS 305/8.2(a-3); 50 IAC 9110.90(B); applicable Illinois workers' compensation fee schedule rules.

Direct Care

• Preferred Provider Program: When an employer maintains an approved PPP network, the employer may direct medical care through participating providers.
• No PPP: Without an approved PPP, the employee generally retains greater provider choice, subject to Illinois' applicable two-choice rules.
• Provider Choices: When the two-choice provision applies, the employer may remain responsible for reasonable and necessary care from the employee's first two selected provider streams and their referrals.

Sources: 820 ILCS 305/8(a) and 305/8(a-1); 50 IAC 9110.70; Illinois Workers' Compensation Commission Benefit Administration Rules.

Pre-Authorization

• Open Formulary: Illinois generally follows an open formulary structure, with generic substitution requirements and applicable carrier or PBM utilization controls.

Source: 820 ILCS 305/8.2; IWCC Fee Schedule Rules.

OTC Restrictions

• Prescription Requirement: OTC medications generally require a valid prescription from the attending provider and a connection to the accepted work injury.
• Pricing: Properly prescribed OTC products generally follow the applicable U&C price or contracted PBM rate.
• NDC Documentation: PBM systems may require original manufacturer NDC information and may cross-reference repackaged or private-label products with the source manufacturer.

Sources: 820 ILCS 305/8.2; 50 IAC 9110.90; applicable PBM pharmacy pricing requirements.

Topical Restrictions

• Retail Pricing: Manufactured topical medications are generally reimbursed using the pharmacy's U&C charge or the lower applicable PBM contract rate.
• NDC Verification: Repackaged topical products may require original manufacturer data for pricing and audit purposes.
• Refill Controls: Recurring topical prescriptions may be subject to renewed prescription or medical-necessity requirements.

Sources: 820 ILCS 305/8.2; 50 IAC 9110.90; applicable PBM pharmacy fee schedule requirements.

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions are reviewed by individual ingredient and quantity using the applicable U&C or contracted PBM pricing.
• NDC Requirement: Each eligible ingredient should have an appropriate manufacturer NDC. Unmapped or unsupported components may be excluded from reimbursement.
• Prior Authorization: Compound prescriptions may require advance authorization before a retail pharmacy can receive payment.

Sources: 820 ILCS 305/8.2; 50 IAC 9110.90; applicable PBM pharmacy requirements.

Timelines

• Submission Period: Pharmacy claims generally must be submitted within the applicable Illinois statutory filing period, including the three-year period identified for pharmacy billing.
• Electronic Claims: Real-time PBM claims are generally adjudicated at the point of sale.
• Paper Claims: Retroactive or paper-submitted claims are subject to applicable payer response requirements.
• Late Payment: Eligible unpaid balances may accrue statutory interest.
• PBM Disputes: Contract-related reversals, audits, and payment issues should first follow the applicable PBM appeal process.
• State Disputes: Unresolved clinical, liability, or reimbursement disputes may proceed through applicable Illinois Workers' Compensation Commission procedures.

Sources: 820 ILCS 305/8.2(d); 50 IAC 9110.70; Illinois Workers' Compensation Commission Rules of Practice.

Pricing Source

• PBM contract rate data
• U&C pricing benchmarks
• Medi-Span

Sources: 820 ILCS 305/8.2; 50 IAC 9110.90; applicable PBM pharmacy fee schedule and network requirements.

State Fee Schedule

• Brand Medications: Brand-name prescriptions are generally reimbursed at 100% of the pharmacy's reasonable U&C charge.
• Generic Medications: Generic prescriptions generally follow the same U&C-based reimbursement approach.
• PBM Contract Rates: When a carrier or employer uses a contracted PBM network, the applicable negotiated network rate may replace the standard U&C amount.
• Lower-of Review: Point-of-sale systems may compare the U&C price, contracted PBM rate, and any applicable employer-negotiated rate and apply the lowest qualifying amount.

Sources: Indiana Code 22-3-3-4; IC 22-3-3-4.5(c); Worker's Compensation Board of Indiana Billing Rules; applicable PBM pharmacy pricing guidance.

Direct Care

• Employer Direction: Indiana follows an employer-directed care model in which the employer or workers' compensation carrier may select and manage the medical providers and pharmacy network used for an industrial injury.
• PBM Network: When a carrier establishes a PBM pharmacy network, prescriptions may need to be filled through participating retail pharmacies.

Sources: Indiana Code 22-3-3-4(a); Worker's Compensation Board of Indiana Administrative Rules; applicable PBM pharmacy guidance.

Pre-Authorization

• ODG Formulary: Indiana uses the ODG Drug Formulary framework. Medications designated as requiring authorization may be blocked at the point of sale until approval is obtained.

Source: Ind. Code 22-3-3-4.7; Worker's Compensation Board Rules.

OTC Restrictions

• Prescription Requirement: OTC medications generally require a valid prescription from the authorized treating provider and must relate to the accepted industrial injury.
• Pricing: Prescribed OTC products generally follow the pharmacy's U&C price or applicable PBM network rate.
• NDC Documentation: Original manufacturer NDC information may be required for pricing and audit purposes.
• Formulary Compliance: OTC medications remain subject to applicable ODG formulary requirements and may require authorization when designated as restricted items.

Sources: Indiana Code 22-3-3-4; IC 22-3-3-4.7; Worker's Compensation Board of Indiana Billing Rules; applicable PBM pharmacy requirements.

Topical Restrictions

• Retail Pricing: Manufactured topical medications are generally processed using the pharmacy's U&C price or the applicable contracted PBM rate.
• NDC Verification: Repackaged or private-label topical products may require source manufacturer NDC information for reimbursement.
• Refill Controls: Repeated topical refills may require an updated prescription or documentation supporting continued medical necessity.
• ODG Requirements: Topical medications subject to an ODG authorization designation require approval before reimbursement.

Sources: Indiana Code 22-3-3-4; IC 22-3-3-4.7; Worker's Compensation Board of Indiana Medical Fee Schedule Guidelines; applicable PBM pharmacy requirements.

Compound Restrictions

• Ingredient-Level Pricing: Compounded prescriptions are reviewed separately by ingredient and quantity using the pharmacy's U&C price or applicable PBM contract rate.
• NDC Requirement: Each ingredient, active pharmaceutical component, chemical, or base should be reported with an applicable NDC. Missing or invalid information may result in no allowance for the affected ingredient.
• Compounding Fee: A $10.00 compounding fee may apply to an eligible compound prescription.
• Prior Authorization: Compounds generally require advance authorization under the applicable ODG formulary requirements.

Sources: Indiana Code 22-3-3-4; IC 22-3-3-4.7; Worker's Compensation Board of Indiana Billing Rules; applicable PBM pharmacy guidance.

Timelines

• Submission Deadline: Pharmacy claims generally must be submitted within 120 calendar days of dispensing under the applicable billing requirements.
• Electronic Claims: PBM claims submitted electronically are generally adjudicated at the point of sale.
• Paper Claims: Properly documented paper or retroactive pharmacy bills are subject to the applicable payer response period.
• Documentation Requests: When additional records are requested, the applicable response period may be paused until the pharmacy supplies the requested information.
• Late Payment: Eligible unpaid balances may accrue statutory interest.
• PBM Appeals: Contract-related payment reversals, audits, or recoupments should generally follow the PBM's internal dispute process first.
• Board Review: Unresolved provider fee disputes may be brought before the Worker's Compensation Board of Indiana using the applicable application process.

Sources: Indiana Code 22-3-3-5.2; IC 22-3-7.2-6; 631 IAC 1-1-28; Worker's Compensation Board of Indiana Rules of Practice.

Pricing Source

• PBM private contract rate data
• U&C benchmarks
• Medi-Span

Sources: Indiana Code 22-3-3-4; IC 22-3-3-4.5; IC 22-3-3-5; 631 IAC 1-1-28; Worker's Compensation Board of Indiana provider guidance.

State Fee Schedule

• Brand-Name Reimbursement: Reimbursement is based on 100% of the pharmacy's reasonable Usual & Customary (U&C) charge to the general public.
• Generic Reimbursement: Generic prescriptions are reimbursed at 100% of the pharmacy's submitted U&C charge when the amount reflects local geographic market conditions.
• PBM Contract Override: When an employer or insurer uses a contracted Pharmacy Benefit Manager (PBM) network, such as Optum, the negotiated network rate supersedes the public U&C reasonable-cost calculation.
• Lesser-Of Rule: Point-of-sale adjudication must apply the lowest applicable amount among the pharmacy's submitted U&C charge, the contracted PBM network rate, and any employer-negotiated fee variance.

Sources: Iowa Code 85.27; Iowa Administrative Code (IAC) Chapter 876 8.1(85); Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates (Updated March 2026).

Direct Care

• Yes: Iowa follows an Employer Direction model. Employers have the statutory authority to select and direct medical providers, care coordinators, and pharmacy networks for covered workplace injuries.
• Prescriptions filled outside the employer's designated PBM network or at an unauthorized retail pharmacy may be denied when the prescription is non-emergency and outside the authorized care pathway.

Sources: Iowa Code 85.27; Iowa Administrative Code (IAC) Rule 876 4.48; Iowa Workers' Compensation Commissioner Manual; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Resource Guide.

Pre-Authorization

• No: Iowa does not have a state-mandated pharmacy fee schedule or centralized closed formulary. Retail pharmacy charges must remain reasonable.

Source: Iowa Code 85.27 / Workers' Compensation Division.

OTC Restrictions

• Prescription Requirement: OTC medications purchased from a retail pharmacy are generally not reimbursable unless supported by a valid, signed prescription from the authorized treating provider connecting the medication to the accepted workplace injury.
• OTC Pricing: When properly prescribed and authorized, OTC medications are reimbursed at the pharmacy's submitted U&C retail price or the lower negotiated PBM network rate.
• Original Manufacturer NDC: The exact NDC for the original manufacturer or source labeler must be captured. Repackaged and private-label products must be mapped to the underlying manufacturer data for pricing and compliance review.
• Medical Necessity Review: Because Iowa does not use a rigid state formulary, carriers and PBMs may apply utilization standards to confirm that the OTC medication is appropriate for the accepted injury.

Sources: Iowa Code 85.27; Iowa Administrative Code (IAC) Chapter 876 8.1(85); Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates.

Topical Restrictions

• Retail Pricing: Non-compounded topical medications filled at retail pharmacies are reimbursed at the pharmacy's U&C public charge or the lower negotiated PBM network rate.
• NDC Verification: PBM systems must verify the product's NDC and identify the original manufacturer, removing secondary repackager or private-label pricing data when applicable.
• Refill Restrictions: Automated recurring refills for retail topical medications are blocked. Each subsequent fill requires a reauthorized prescription with documentation supporting continued medical necessity.
• Medical Necessity Review: Carriers and PBMs may review topical medications using evidence-based utilization standards to confirm that the treatment corresponds with the accepted workplace injury.

Sources: Iowa Code 85.27; Iowa Administrative Code (IAC) Chapter 876 8.1(85); Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates.

Compound Restrictions

• Ingredient-Level Pricing: Retail compounds are priced by individual ingredient and metric quantity. Reimbursement is based on the pharmacy's U&C charge or the lower negotiated PBM network rate.
• NDC Requirement: Each active ingredient, API, bulk chemical, or vehicle base must be submitted with its valid registered NDC. Missing or invalid NDC information may result in a $0.00 allowance for that ingredient.
• Compounding Fee: Without a specific state statutory cap, the compounding labor or professional fee is evaluated against local market conditions or applicable PBM contract limits.
• Prior Authorization: Custom multi-ingredient compounds are subject to upfront clinical authorization. The pharmacy clearinghouse may reject the transaction unless an active authorization number is provided by the carrier or PBM.

Sources: Iowa Code 85.27; Iowa Administrative Code (IAC) Chapter 876 8.1(85); Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Resource Guide (Updated March 2026).

Timelines

• Pharmacy Billing Deadline: Retail pharmacies must submit electronic or paper claims within 365 calendar days of dispensing.
• Payer Payment/Denial Window: Electronic PBM claims are adjudicated in real time. Paper or manually reviewed pharmacy invoices must generally be paid or accompanied by an Explanation of Review (EOR) within 30 calendar days of receipt.
• Employee Hold-Harmless: When care is directed by the employer, the injured employee must be protected from responsibility for the pharmacy bill. Pharmacies may not balance bill the employee while the claim remains active.
• Late Payment Interest: Unpaid undisputed bills may accrue interest after the 30-day payment period. The rate is based on the five-year U.S. Treasury bond rate plus 2.0%, beginning on the 31st day after receipt.
• PBM Disputes: Pharmacy disputes involving PBM reversals, audits, recoupments, or contract payments must first proceed through the PBM's internal appeal process.
• State Dispute Deadline: If a dispute involving an uncontracted pharmacy remains unresolved, the provider may file a Petition for a Contested Case Proceeding with the Iowa Workers' Compensation Commissioner. The filing period is two years from the injury date or three years from the last indemnity benefit payment.

Sources: Iowa Code 85.26; Iowa Code 85.27(4); Iowa Code 85.30; Iowa Administrative Code (IAC) Rule 876 4.1; Iowa Workers' Compensation Commissioner Contested Case Rules.

Pricing Source

• PBM private contract rates, Usual & Customary (U&C) benchmarks, and Medi-Span.

Sources: Iowa Code 85.26; Iowa Code 85.27; Iowa Code 85.30; Iowa Administrative Code (IAC) Rule 876 8.1(85); Iowa Division of Workers' Compensation Provider Administration Guidance.

State Fee Schedule

• Brand-Name Reimbursement: AWP × 0.90 + $3.00 dispensing fee.
• Generic Reimbursement: AWP × 0.85 + $5.00 dispensing fee.
• PBM Contract Override: When an insurer uses a contracted PBM network, such as Optum, the negotiated network rate takes precedence over the statutory fee schedule when it produces the lower reimbursement.
• Lesser-Of Rule: Point-of-sale processing applies the lowest amount among the statutory AWP formula, the pharmacy's submitted U&C price, and the negotiated PBM network rate.

Sources: Kansas Administrative Regulations (K.A.R.) 44-5-110; Kansas Department of Labor Workers' Compensation Schedule of Medical Fees; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Resource Guide.

Direct Care

• Yes: Kansas follows an Employer Direction framework. Employers and insurers may select and direct providers, care coordinators, and pharmacy networks for workplace injuries.

Sources: Kansas Statutes Annotated (K.S.A.) 44-510h; Kansas Department of Labor Workers' Compensation Division Guidance.

Pre-Authorization

• Yes: Kansas uses the ODG Appendix A Drug Formulary. Non-preferred or "N" status medications require prospective pre-certification.

Source: K.S.A. 44-510j / Kansas Department of Labor Rules.

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid prescription from the authorized treating provider establishing a connection to the accepted workplace injury.
• Pricing: Prescribed OTC medications follow the generic reimbursement formula of AWP × 0.85 + $5.00 dispensing fee.
• NDC Verification: The original manufacturer's NDC must be reported. Repackaged and private-label products must be linked to the underlying manufacturer data.
• ODG Requirements: Prescribed OTC medications remain subject to the mandatory ODG formulary. An "N" status drug requires prior authorization even when the product is available over the counter.

Sources: Kansas Administrative Regulations (K.A.R.) 44-5-110; Kansas Department of Labor Workers' Compensation Schedule of Medical Fees; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates.

Topical Restrictions

• Retail Pricing: Brand topical medications are reimbursed at AWP × 0.90 + $3.00. Generic topical medications use AWP × 0.85 + $5.00.
• $200 Topical Cap: Reimbursement for a topical medication is limited to the lesser of $200 for a 30-day supply or the applicable standard fee schedule amount. The cap is prorated for different supply periods.
• NDC Verification: PBM systems must identify the original manufacturer's NDC and remove secondary repackager or private-label pricing data from the calculation.
• ODG Prior Authorization: Topical medications are subject to the ODG closed formulary. Products with an "N" status require approved prior authorization before dispensing.
• Refill Restrictions: Automated recurring refills are not permitted. Each subsequent topical fill requires a reauthorized prescription documenting continued medical necessity.

Sources: Kansas Administrative Regulations (K.A.R.) 44-5-110; Kansas Department of Labor Schedule of Medical Fees Guidelines; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates (Updated March 2026).

Compound Restrictions

• Pricing: Compounded prescriptions use AWP × 0.85 + $5.00 generic dispensing fee.
• NDC Requirement: Each compound ingredient must be submitted using its valid original manufacturer NDC. Missing, unmapped, or invalid NDC information may result in a $0.00 allowance.
• Compounding Fee: A single professional compounding fee may be applied and is subject to applicable market or PBM contract limits.
• Prior Authorization: Custom compounds require prior authorization. The pharmacy clearinghouse may reject the claim unless an active clinical authorization is provided.

Sources: Kansas Administrative Regulations (K.A.R.) 44-5-110; Kansas Department of Labor Workers' Compensation Schedule of Medical Fees; Optum Workers' Compensation Pharmacy Fee Schedule & Compounded Medications Guide (Updated March 2026).

Timelines

• Pharmacy Billing Deadline: Retail pharmacy claims must be submitted within 365 calendar days of dispensing.
• Payer Payment/Denial Window: Electronic PBM claims are processed immediately. Paper or manually reviewed bills must generally be paid or formally denied within 30 calendar days of receipt.
• Provider Reconsideration: A pharmacy disputing an audit reversal or payment reduction must submit a written reconsideration request within 30 calendar days of the dispute notice.
• Informal Hearing: If a pharmacy receives no response after submitting a bill and subsequent follow-up, it may request an Informal Hearing before the Director of the Workers' Compensation Division under the stated statutory process.
• Employee Hold-Harmless: Pharmacies may not balance bill an injured worker when the prescription was authorized under an active workers' compensation claim.
• Judicial Review: Following the administrative process, an appeal of a final medical fee determination must be filed with the Workers Compensation Appeals Board within 10 calendar days of the decision.

Sources: K.S.A. 44-510j; K.S.A. 44-534; Kansas Department of Labor Division of Workers' Compensation Medical Dispute Resolution Procedures.

Pricing Source

• PBM private contract rates and Medi-Span or First Databank AWP data.

Sources: K.S.A. 44-510i; K.A.R. 51-9-7; Kansas Department of Labor Medical Services Division Administration Manual; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• Brand-Name Reimbursement: AWP × 0.90 + $5.00 dispensing fee.
• Generic Reimbursement: 85% of the AWP of the lowest-priced equivalent drug product + $5.00 dispensing fee.
• Dispensing Fee: Kentucky provides a uniform $5.00 professional dispensing allowance for each prescription line.
• Lesser-Of Rule: Reimbursement is based on the lowest applicable amount among the statutory AWP formula, the pharmacy's U&C price, and any lower PBM network contract rate.
• Auto PIP Reference: Kentucky House Bill 627 connects Auto Personal Injury Protection medical reimbursement to the Kentucky Workers' Compensation fee schedule.

Sources: Kentucky Administrative Regulations (K.A.R.) 803 KAR 25:092 Section 2; Kentucky Department of Workers' Claims Medical Fee Schedule; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Resource Guide.

Direct Care

• No: Kentucky is generally an Employee Choice state for primary clinical care. Under KRS 342.020(4), an injured worker has the right to select the initial treating provider.
• When an employer uses a state-certified Workers' Compensation Managed Health Care Plan under 803 KAR 25:110, provider selection must be made from the plan's approved network.

Sources: Kentucky Revised Statutes (KRS) 342.020; Kentucky Administrative Regulations (KAR) 803 KAR 25:096; 803 KAR 25:110; Optum Workers' Compensation Managed Health Care Plan Certified Network Guidelines.

Pre-Authorization

• Yes: Kentucky requires the use of the closed ODG Drug Formulary. Non-preferred drug classes may be subject to point-of-sale authorization requirements.

Source: KRS Chapter 342 / Department of Workers' Claims.

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless accompanied by a valid prescription from the authorized treating provider establishing medical necessity for the accepted workplace injury.
• Pricing: Validly prescribed OTC products are reimbursed at 85% of the AWP of the lowest-priced equivalent drug product + $5.00 dispensing fee.
• Dispensing Fee: Prescribed OTC products filled by a licensed pharmacist qualify for the standard $5.00 dispensing fee.
• NDC Verification: The original manufacturer's NDC must be reported, with repackaged or private-label products mapped back to the source manufacturer.
• ODG Requirements: Prescribed OTC medications must comply with the ODG closed formulary. "N" status products require prior authorization.

Sources: Kentucky Administrative Regulations (K.A.R.) 803 KAR 25:092; 803 KAR 25:270; Kentucky Department of Workers' Claims Pharmacy Fee Schedule Rules.

Topical Restrictions

• Pricing: Brand topical medications are calculated at AWP × 0.90 + $5.00. Generic topical medications use 85% of the AWP of the lowest-priced equivalent drug product + $5.00.
• NDC Verification: PBM systems must identify the original manufacturer's NDC and remove secondary repackager or private-label pricing data from the reimbursement calculation.
• ODG Prior Authorization: Topical medications are subject to the ODG closed formulary. An "N" status topical product requires utilization review approval before dispensing.
• Refill Restrictions: Automated recurring topical refills are blocked. Subsequent fills require a new verified prescription documenting continued medical necessity.

Sources: Kentucky Administrative Regulations (K.A.R.) 803 KAR 25:092; 803 KAR 25:270; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates (Updated March 2026).

Compound Restrictions

• Ingredient Pricing: Each ingredient in a compounded prescription is priced separately using 85% of the AWP of the lowest-priced equivalent drug product + $5.00 dispensing fee.
• NDC Requirement: Each ingredient must use the original manufacturer's or raw chemical supplier's NDC. Repackager or pharmacy-assigned NDCs cannot be substituted under the stated billing rules.
• Single Dispensing Fee: Only one $5.00 professional dispensing fee applies to the completed compound. Separate compounding labor or handling markups cannot be stacked onto the bill.
• Prior Authorization: Custom compounds require prior authorization under the ODG requirements. Claims without an active authorization may be rejected at the point of sale.

Sources: Kentucky Administrative Regulations (K.A.R.) 803 KAR 25:092; 803 KAR 25:270; Optum Workers' Compensation Pharmacy Fee Schedule & Compounded Medications Guide (Updated March 2026).

Timelines

• Pharmacy Billing Deadline: Retail pharmacy bills must be submitted within 45 calendar days of dispensing. Late submissions may become permanently non-reimbursable.
• Payer Payment/Denial Window: Electronic PBM transactions are adjudicated immediately. Paper invoices and manual billing overrides are subject to a 30-day payment or denial window.
• Medical Bill Audit Reconsideration: A pharmacy disputing an audit reduction or fee calculation must request Medical Bill Audit (MBA) reconsideration within 30 calendar days of receiving the carrier's Explanation of Review.
• Formal Medical Fee Dispute: If reconsideration does not resolve the issue, the pharmacy must file a Form 112 Medical Fee Dispute within 30 calendar days of the carrier's final audit determination.
• Employee Hold-Harmless: Pharmacies may not balance bill an injured worker for authorized prescriptions under an active claim.
• Administrative Appeal: After a Form 112 proceeding, an appeal of the ALJ's final fee determination must be submitted to the Workers' Compensation Board within 30 calendar days.

Sources: KRS 342.020(4); Kentucky Administrative Regulations (KAR) 803 KAR 25:096; 803 KAR 25:012; Kentucky Supreme Court Binding Precedents (Timely Filing Limits enforced 2023-2026).

Pricing Source

• Medi-Span or Red Book.

Sources: KRS 342.035; 803 KAR 25:092; 803 KAR 25:270; Kentucky Department of Workers' Claims Medical Administration Manual.

State Fee Schedule

• Brand-Name Reimbursement: AWP × 1.10 + $11.81 dispensing fee.
• Generic Reimbursement: AWP × 1.40 + $11.81 dispensing fee.
• Dispensing Fee: Louisiana ties the professional dispensing allowance to the state Medicaid dispensing fee, currently listed as $11.81 per prescription line for both brand and generic medications.
• Lesser-Of Rule: The final reimbursement is the lowest applicable amount among the statutory AWP formula, the pharmacy's U&C price, and any lower PBM network contract rate.

Sources: Louisiana Administrative Code (LAC) Title 40, Part I, Subpart 2, Chapter 29, Section 2907; Louisiana Department of Health Pharmacy Services Medicaid Directory Guide; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Resource Guide.

Direct Care

• No: Louisiana does not allow employers or insurers to require injured workers to use a particular retail pharmacy, mail-order provider, or proprietary PBM network.
• An employee may choose a local independent pharmacy instead of an insurer's preferred pharmacy network.

Sources: La. R.S. 23:1121; La. R.S. 23:1203(A); Louisiana Administrative Code (LAC) Title 40, Part I, Subpart 2, Chapter 29; Louisiana Office of Workers' Compensation Administration Guidelines.

Pre-Authorization

• No: Louisiana follows an open baseline with retrospective medical-necessity review. House Bill 1047 was introduced in 2026 to address authorization requirements for prescription drugs.

Source: La. R.S. 23:1203 / 2026 House Bill 1047.

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid prescription from the authorized treating provider linking the medication to the accepted workplace injury.
• $50 Authorization Threshold: Prescribed OTC medications with a calculated fee schedule amount above $50 require prior authorization using Form LWC-WC-1010. Without approval, payer liability is limited to $50.
• Pricing: Properly prescribed OTC medications use the generic formula of AWP × 1.40 + $11.81 dispensing fee.
• Dispensing Fee: Licensed retail pharmacies receive the $11.81 professional dispensing allowance.
• NDC Verification: The original manufacturer's NDC must be captured, with repackaged or private-label products mapped to the underlying manufacturer.

Sources: La. R.S. 23:1142; Louisiana Administrative Code (LAC) Title 40, Part I, Subpart 2, Chapter 29, Sections 2905 & 2907; Louisiana Office of Workers' Compensation Administration Guidelines.

Topical Restrictions

• Pricing: Brand topical medications use AWP × 1.10 + $11.81. Generic topical medications use AWP × 1.40 + $11.81.
• $50 Authorization Threshold: Topical medications exceeding $50 in calculated fee schedule cost require prospective authorization through Form LWC-WC-1010. Without authorization, payer liability is capped at $50.
• NDC Verification: PBM systems must identify the original manufacturer's NDC and remove secondary repackager or private-label pricing data from the calculation.
• Refill Restrictions: Automated recurring refills are blocked. Each subsequent topical fill requires a new verified prescription documenting continued medical necessity.

Sources: La. R.S. 23:1142; Louisiana Administrative Code (LAC) Title 40, Part I, Subpart 2, Chapter 29, Sections 2905 & 2907; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Ingredient Pricing: Each ingredient in a retail compound is priced separately using the generic formula of AWP × 1.40 + $11.81.
• Single Dispensing Fee: Only one $11.81 professional dispensing fee applies to the completed compound. Separate handling fees cannot be added for individual ingredients.
• NDC Requirement: Each component must be submitted using the original manufacturer's or bulk chemical supplier's NDC. Repackager or pharmacy-assigned placeholder NDCs may be rejected.
• $50 Authorization Threshold: Compounds exceeding the $50 threshold require prospective authorization through Form LWC-WC-1010. Without authorization, payer liability is limited to $50.

Sources: Louisiana Administrative Code (LAC) Title 40, Part I, Subpart 2, Chapter 29, Section 2907(D); La. R.S. 23:1142; Optum Workers' Compensation Pharmacy Fee Schedule & Compounded Medications Guide (Updated March 2026).

Timelines

• Pharmacy Billing Deadline: Retail pharmacies must submit properly coded bills within 365 calendar days of dispensing.
• Payer Payment/Denial Window: Electronic transactions are adjudicated immediately. Paper invoices are subject to a 60-day payment or denial period, while the stated electronic clearinghouse payment deadline is 30 days.
• Medical Director Appeal: A pharmacy or provider disputing a denial or modification of a medication costing more than $50 may file Form LWC-WC-1009 with the OWC Medical Director within 15 calendar days.
• Medical Director Review: The OWC Medical Director must issue a determination within 30 calendar days after receiving the completed Form 1009 package.
• Employee Hold-Harmless: Pharmacies may not balance bill an injured worker for prescriptions provided under an active, authorized claim.
• Judicial Appeal: A party challenging the Medical Director's determination must file Form LWC-WC-1008 with the appropriate Workers' Compensation District Office within 15 calendar days of the determination's mailing date.

Sources: La. R.S. 23:1201; La. R.S. 23:1203.1; La. R.S. 23:1142; Louisiana Administrative Code (LAC) Title 40, Part I, Subpart 2, Chapter 27.

Pricing Source

• Medi-Span or Red Book.

Sources: La. R.S. 23:1034.2; La. R.S. 23:1203.1; Louisiana Administrative Code (LAC) Title 40, Part I, Subpart 2, Chapter 29; Louisiana Workforce Commission Bulletins (2025-2026).

State Fee Schedule

• Brand-Name Reimbursement: Brand medications are reimbursed at the lower of the pharmacy's documented U&C charge or the carrier's negotiated PBM contract rate.
• Generic Reimbursement: Generic medications follow the same U&C or contracted network pricing approach under Chapter 5, Section 1.06(2).
• Dispensing Fee: Maine does not provide a separate statutory pharmacy dispensing fee. Professional handling costs must be included within the pharmacy's U&C price.
• Lesser-Of Rule: PBM and clearinghouse systems may reduce reimbursement to the lowest applicable amount among the submitted U&C price, regional cash-market pricing, and the negotiated PBM network rate.

Sources: Maine Revised Statutes Annotated (M.R.S.A.) Title 39-A, 206 & 209-A; Maine Workers' Compensation Board (WCB) Rules and Regulations, Chapter 5, Section 1.06; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Yes: Maine permits employers or insurers to select a provider, facility, or managed care pharmacy program during the first 10 days of healthcare services.
• After the initial 10-day period, the injured worker may select their own treating provider and licensed retail pharmacy, subject to the stated notification requirements.

Sources: 39-A M.R.S.A. 206(1)-(2); Maine Workers' Compensation Board Rules and Regulations, Chapter 5.

Pre-Authorization

• No: Maine uses an open formulary approach with generic substitution requirements and employer utilization networks.

Source: Me. Rev. Stat. tit. 39-A, 206 / WCB Rules.

OTC Restrictions

• Prescription Requirement: OTC medications are generally not reimbursable unless supported by a valid prescription or medical order from the authorized treating provider connecting the medication to the accepted work injury.
• Pricing: Prescribed OTC products are reimbursed at the lower of the pharmacy's documented U&C retail price or the negotiated PBM network rate.
• No Separate Handling Fee: Maine does not provide a standalone statutory dispensing fee. Handling and administrative costs must be included in the pharmacy's U&C price.
• No Prior Authorization: Carriers cannot require prior authorization as a condition of payment for prescribed retail OTC products.
• Retrospective Review: Carriers may review the medical necessity of OTC medications after dispensing. If a claim is disputed, the carrier must pay undisputed portions and file a Form WCB-21 Notice of Controversy within 30 calendar days of receiving the bill.

Sources: M.R.S.A. Title 39-A, 206; Maine WCB Rules and Regulations, Chapter 5, Sections 1.05, 1.06, and 1.07.

Topical Restrictions

• Retail Pricing: Non-compounded topical medications are reimbursed at the lower of the pharmacy's U&C charge or the carrier's negotiated PBM rate.
• No Prior Authorization: Carriers and self-insured employers cannot require prospective authorization as a condition of payment for prescribed retail topical medications.
• Retrospective Review: Carriers may later review topical medications for medical necessity and deny products that do not align with the accepted injury or applicable care standards.
• NDC Verification: Retail bills must identify the original manufacturer's NDC. Secondary repackager and private-label NDCs may be removed during bill review.
• Notice of Controversy: If a carrier disputes a topical medication, it must pay undisputed portions and file Form WCB-21 within 30 calendar days of receiving the bill.

Sources: M.R.S.A. Title 39-A, 206 & 209-A; Maine WCB Rules and Regulations, Chapter 5, Sections 1.05, 1.06, and 1.07.

Compound Restrictions

• Pricing: Retail compounds are reimbursed at the lower of the pharmacy's U&C charge or the carrier's negotiated PBM network rate.
• No Separate Compounding Fee: Maine does not provide a separate statutory dispensing or compounding fee. Related costs must be included within the pharmacy's overall U&C price.
• No Prior Authorization: Carriers and self-insured employers cannot require prospective authorization as a condition of payment for prescribed compounds.
• Retrospective Review: Carriers may review compounds after dispensing to determine whether the ingredients have a therapeutic purpose connected to the accepted workplace injury.
• Notice of Controversy: When a compound is disputed, the carrier must pay undisputed portions and file Form WCB-21 within 30 calendar days of receiving the bill.

Sources: M.R.S.A. Title 39-A, 206 & 209-A; Maine WCB Rules and Regulations, Chapter 5, Sections 1.05, 1.06, and 1.07.

Timelines

• Pharmacy Billing Deadline: Retail pharmacy invoices must be submitted within 365 calendar days of dispensing.
• Payer Payment/Denial Window: Employers and insurers generally have 30 calendar days after receiving a properly documented pharmacy bill to pay or formally deny it.
• Late Payment Penalty: If an undisputed bill remains unpaid after the initial 30-day period, the provider must send a certified notice of nonpayment. If payment is still not made within another 30 days, a $50-per-day penalty may accrue, capped at $1,500.
• Retroactive Dispute: Since prospective prior authorization is prohibited, disputes are handled retrospectively. A carrier challenging medical necessity must pay undisputed portions and file Form WCB-21 within 30 calendar days of receiving the bill.
• Employee Hold-Harmless: Injured workers are protected from balance billing during active billing disputes.
• Formal Board Review: If a dispute remains unresolved after the applicable mediation process, the pharmacy or carrier may file Form WCB-100 for a formal Petition for Award of Medical Benefits and an evidentiary hearing before an Administrative Law Judge.

Sources: M.R.S.A. Title 39-A, 205(4) & 206; Maine WCB Rules and Regulations, Chapter 5, Sections 1.05, 1.06, and 1.07.

Pricing Source

• Documented pharmacy public cash-price ledger and PBM internal network index.

Sources: M.R.S.A. Title 39-A, 205, 206, and 209-A; Maine WCB Rules and Regulations, Chapter 5, Sections 1.05 & 1.06; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• Federal AWP Pricing Standard: Retail pharmacy claims for maritime employees covered by the Longshore and Harbor Workers' Compensation Act (LHWCA), 33 U.S.C. 901 et seq., are processed under the U.S. Department of Labor (DOL) Office of Workers' Compensation Programs (OWCP) Medical Fee Schedule. Retail transactions are not calculated using individual state pharmacy markup schedules or ordinary public cash pricing.
• Brand-Name Calculation: Brand medications are reimbursed at AWP × 0.90, plus a $4.00 professional dispensing fee.
• Generic Calculation: Generic medications are reimbursed at AWP × 0.75, plus a $4.00 professional dispensing fee.
• Dispensing Fee Limit: The professional dispensing allowance is limited to $4.00 under the OWCP structure. Retail pharmacies cannot increase this amount based on location, operating costs, or pharmacy type. Additional sales taxes or processing charges cannot be added to the claim.
• Lesser-of Pricing: Claims are evaluated using the lowest applicable amount among the federal OWCP calculation, the pharmacy's submitted Usual & Customary (U&C) price, and any applicable PBM contract rate.

Sources: Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 901 et seq.; 20 CFR 702.413; U.S. Department of Labor, OWCP Pharmacy Fee Schedule Framework.

Direct Care

• No: Maritime employees retain the right to use a licensed retail pharmacy of their choice for valid prescriptions. Employers cannot require an injured worker to use a specific mail-order pharmacy or penalize the worker for choosing an independent storefront.

Sources: Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 907(b) & (c); 20 CFR 702.403.

Pre-Authorization

• No: The LHWCA does not establish a single nationwide closed drug formulary. Necessary prescriptions are processed through applicable carrier and PBM systems, which may apply utilization controls, generic substitution requirements, and medication-duration limits.

Source: Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 907.

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless a valid written prescription or clinical order from the authorized treating physician connects the medication to the accepted workplace injury.
• Generic Pricing Treatment: A prescribed OTC medication is treated as a generic item for pricing purposes and is limited to AWP × 0.75 plus the $4.00 dispensing fee.
• Single Dispensing Allowance: Only one $4.00 professional dispensing fee applies. Additional handling or processing fees cannot be added.
• Retrospective Review: Routine OTC prescriptions may be dispensed without prospective authorization, but the carrier can later review the claim. Items determined to be unrelated or non-compensable may be denied.

Sources: Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 907; 20 CFR 702.413; U.S. Department of Labor, OWCP Medical Fee Schedule Guidelines.

Topical Restrictions

• Brand and Generic Pricing: Commercial topical medications filled at retail pharmacies follow the federal pricing structure. Brand topicals are limited to AWP × 0.90 plus $4.00, while generic topicals are limited to AWP × 0.75 plus $4.00.
• NDC Verification: Repackaged or secondary NDC information is reviewed against the original manufacturer's product information to establish the appropriate AWP.
• Specialty Topicals: High-cost patches and specialized topical products may trigger utilization review and require documentation supporting medical necessity before payment is authorized.
• Refill Controls: Subsequent topical fills may be subject to clinical renewal requirements to confirm continued medical necessity.

Sources: Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 907; 20 CFR 702.413; U.S. Department of Labor OWCP Fee Schedule Instructions.

Compound Restrictions

• Ingredient-Level Review: Compounded prescriptions are evaluated by individual ingredient. Brand ingredients use AWP × 0.90, while generic ingredients use AWP × 0.75.
• Single Dispensing Fee: The entire compound receives one $4.00 dispensing allowance. Separate fees cannot be added for individual ingredients or compounding labor.
• Manufacturer NDC Requirement: Each ingredient must be submitted using the appropriate original manufacturer or bulk supplier NDC. Invalid, missing, or pharmacy-created codes may result in rejection or a $0.00 allowance for that component.
• Prior Authorization: Custom compounds may require advance carrier authorization before the prescription is prepared and dispensed.

Sources: 20 CFR 30.710; U.S. Department of Labor, OWCP Pharmacy Fee Schedule Update; Federal Register Vol. 78, No. 248.

Timelines

• Billing Deadline: Retail pharmacies must submit properly coded claims within 365 days of dispensing. Claims submitted after the applicable deadline may be administratively denied.
• Payer Review Period: The employer or carrier has 30 calendar days after receiving a properly documented bill to pay the claim or formally dispute it.
• Late-Payment Penalty: Under 33 U.S.C. 914(f), an undisputed amount that remains unpaid after the applicable period may be subject to a 20% statutory penalty.
• Formal Dispute Notice: A disputed or denied claim must be formally addressed through the applicable OWCP process, including Form LS-207 where required.
• Worker Protection: The injured employee is not responsible for disputed pharmacy balances and cannot be balance billed for covered charges.
• Dispute Resolution: Unresolved disputes may proceed through an OWCP informal conference and, when necessary, to the Office of Administrative Law Judges.

Sources: Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 914(b), (f) & 919; 20 CFR 702.251 & 702.311.

Pricing Source

• U.S. Department of Labor OWCP Dynamic AWP Database / Medi-Span Index.

Sources: 33 U.S.C. 939; 20 CFR 702.413–702.417; U.S. Department of Labor OWCP Fee Schedule Methodology Guides

State Fee Schedule

• Brand Medication: Retail brand prescriptions are generally limited to the lesser of the pharmacy's submitted U&C charge or the applicable community pricing standard.
• Generic Medication: Generic prescriptions are evaluated against prevailing retail pricing and applicable market benchmarks.
• Dispensing Fee: Maryland does not establish a separate statutory retail pharmacy dispensing fee under the stated framework. Pharmacy overhead and handling costs are incorporated into the applicable retail charge rather than added as a separate fee.
• Lesser-of Review: Claims may be evaluated against the pharmacy's U&C price, applicable community pricing, and any contracted PBM rate.

Sources: Maryland Labor and Employment Article, 9-660 & 9-663; COMAR 14.09.03.01; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• No: Maryland provides employees with broad choice regarding treating providers. This also allows an injured worker to use a licensed pharmacy for an authorized prescription rather than being required to use a specific pharmacy vendor.

Sources: Maryland Labor and Employment Article, 9-660 & 9-663; COMAR 14.09.03.01.

Pre-Authorization

• No: Maryland does not use one centralized state formulary for these claims. Individual carriers may apply prospective or retrospective utilization review.

Source: Md. Code Ann., Lab. & Empl. 9-660 / WCC.

OTC Restrictions

• Prescription Requirement: OTC medications require a valid physician prescription or clinical order establishing their relationship to the accepted work injury.
• Reasonable Pricing: Prescribed OTC products are reimbursed using a reasonable-cost standard rather than a fixed AWP percentage formula.
• Simple OTC Items: An OTC item dispensed as a standalone product does not receive a separate dispensing fee.
• Compounded OTC Ingredients: When an OTC ingredient becomes part of a pharmacist-prepared compound, the completed compound may qualify for the applicable $10.00 professional compounding allowance.
• Retrospective Review: Routine OTC items may be dispensed before authorization, but the carrier may later determine that an item is unrelated, excessive, or otherwise non-compensable.

Sources: Maryland Labor and Employment Article, 9-660 & 9-663; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Community Pricing Standard: Commercial topical prescriptions are generally evaluated against the pharmacy's U&C rate and the prevailing local cost for the product.
• NDC Review: Secondary or repackaged NDCs may be reviewed against the original manufacturer's pricing information.
• Specialty Products: Expensive topical products, including specialized patches and gels, may require medical-necessity documentation and prospective authorization.
• Refill Review: Continued topical treatment may be subject to utilization review and updated documentation supporting ongoing medical necessity.

Sources: Maryland Labor and Employment Article, 9-660 & 9-663; COMAR 14.09.03.01; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Ingredient Reporting: Each ingredient in a compound must be separately identified with the applicable quantity and NDC information.
• Market-Based Pricing: Individual components are evaluated using applicable U&C and prevailing market pricing rather than a fixed AWP percentage.
• Compounding Fee: Maryland allows one $10.00 professional compounding fee per prescription. Multiple handling fees cannot be stacked.
• NDC Requirement: Original manufacturer or bulk supplier NDC information must be provided for each ingredient. Invalid or missing information may result in rejection or a $0.00 allowance.
• Authorization: Custom compounds may require advance carrier approval before dispensing.

Sources: Maryland Labor and Employment Article, 9-660 & 9-663; COMAR 14.09.03.01 & 14.09.08.04; Maryland Workers' Compensation Commission Fee Guide Guidelines; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should be submitted within 12 months of the applicable dispensing, claim acceptance, or compensability date. Late claims may require a showing of good cause.
• Payer Response: The carrier generally has 45 calendar days to pay or formally deny a properly submitted bill.
• Late Interest: Unpaid balances beyond the applicable period may accrue statutory interest at 10% per year.
• Employee Protection: Workers are not responsible for disputed pharmacy balances and cannot be balance billed for covered services.
• Dispute Process: Pharmacy reimbursement disputes may be presented to the Maryland Workers' Compensation Commission using the applicable medical-service dispute process.

Sources: Maryland Labor and Employment Article, 9-660 & 9-663; COMAR 14.09.08.06.

Pricing Source

• Regional prevailing retail and cash-market pricing index.

Sources: Maryland Labor and Employment Article, 9-660 & 9-663; COMAR 14.09.03.01 & 14.09.08.06; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• MassHealth-Based Pricing: Massachusetts workers' compensation pharmacy pricing follows the state's prescribed-drug pricing methodology.
• Brand Formula: Brand prescriptions are limited to the lowest applicable amount among MMAC, AAC, or U&C, plus the $10.02 professional dispensing fee.
• Generic Formula: Generic prescriptions are evaluated using the lowest applicable FUL, MMAC, AAC, or U&C amount, plus the $10.02 dispensing fee.
• Retail Dispensing Fee: The $10.02 professional dispensing allowance applies to qualifying retail pharmacy transactions.

Massachusetts confirms that workers' compensation prescription drug rates reference the state's prescribed-drug regulation, with EOHHS establishing applicable payment rates.

Sources: Massachusetts EOHHS 101 CMR 331.00; 114.3 CMR 40.00; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• No: Massachusetts provides employees significant provider-choice protections under M.G.L. c. 152. Authorized prescriptions may be filled through a licensed pharmacy or applicable pharmacy program.

Sources: Massachusetts General Laws, Chapter 152, Section 30; 114.3 CMR 40.00.

Pre-Authorization

• No: Massachusetts uses an open structure with applicable brand and generic pricing calculations and carrier utilization controls.

Source: Mass. Gen. Laws c. 152, §30 / DIA Rules.

OTC Restrictions

• Prescription Requirement: OTC products require a valid prescription or clinical order connecting the product to the accepted workplace injury.
• Lesser-of Pricing: Prescribed OTC medications are evaluated using the applicable FUL, MMAC, AAC, or U&C amount, plus the $10.02 professional dispensing fee.
• Compound Treatment: A standalone OTC product is evaluated separately, while an OTC ingredient incorporated into a compound is handled under the applicable compound rules.
• Retrospective Review: Carriers may review OTC claims after dispensing and deny products determined to be unnecessary or unrelated to the compensable injury.

Sources: Massachusetts General Laws, Chapter 152, Section 30; 114.3 CMR 40.00; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Four-Tier Pricing: Commercial topical medications are processed using the applicable brand or generic pricing methodology. Qualifying retail transactions receive the $10.02 professional dispensing fee.
• NDC Verification: Repackaged product information may be checked against the original manufacturer's pricing data.
• Specialty Topicals: Higher-cost patches and specialized gels may be subject to utilization review and medical-necessity documentation.
• Refill Controls: Continued topical treatment may require updated clinical documentation.

Sources: 114.3 CMR 40.00; 452 CMR 6.00; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Component Reporting: Each active compound ingredient must be separately reported with the applicable quantity and NDC.
• Ingredient Pricing: Components are evaluated under the applicable FUL, MMAC, AAC, or U&C methodology.
• One Dispensing Fee: The completed compound receives one $10.02 professional dispensing fee rather than multiple fees for individual components.
• NDC Documentation: Original manufacturer or bulk supplier NDC information must accompany each ingredient. Invalid or missing NDCs may be rejected.
• Authorization: Compounds may be subject to prospective utilization review and carrier authorization.

Sources: 114.3 CMR 40.00; 452 CMR 6.00; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims must be submitted within the applicable 90-day period from dispensing under the stated Massachusetts administrative framework.
• Payer Review Period: Carriers have 45 calendar days to pay or formally dispute a properly submitted bill.
• Late Interest: Unpaid eligible balances may accrue statutory interest at 12% per year after the applicable payment period.
• Employee Protection: Workers are protected from balance billing for covered workers' compensation pharmacy services.
• DIA Dispute Process: Unresolved third-party billing disputes may be submitted to the Department of Industrial Accidents through the applicable Form 115 process.

Sources: Massachusetts General Laws, Chapter 152, Sections 13 & 30; 452 CMR 6.00.

Pricing Source

• MassHealth Drug Pricing Reference File / MMAC, AAC, and FUL indices.

Sources: Massachusetts General Laws, Chapter 152, Section 13; 114.3 CMR 40.00; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• AWP-Based Pricing: Michigan retail prescription medications follow the state's AWP-based reimbursement methodology, with pricing references including Red Book and Medi-Span.
• Brand Formula: Single-source brand medications are limited to AWP × 0.90 plus a $3.50 dispensing fee.
• Generic Formula: Multi-source generic medications are calculated at AWP × 0.90 plus a $5.50 dispensing fee.
• Lesser-of Rule: The payable amount is limited to the lower of the applicable fee-schedule amount or the pharmacy's U&C charge.
• NDC Verification: Original manufacturer NDC information is used to establish the applicable pricing baseline.

Michigan's workers' compensation program confirms the state's 28-day provider-selection period before an injured worker may change treating providers.

Sources: Michigan Administrative Code R. 418.101003a(1); MCL 418.315(2); Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Yes: Michigan allows employer or carrier direction of medical care during the first 28 days following the injury. After that period, the employee may select another qualified treating provider under the applicable rules.

Sources: MCL 418.315(1) & (2); Michigan Workers' Disability Compensation Act Health Care Services Rules.

Pre-Authorization

• No: Pharmacy reimbursement follows the applicable state fee manuals and utilization controls, including generic-substitution requirements and medical-necessity review.

Source: Mich. Comp. Laws 418.315 / WCA Rules.

OTC Restrictions

• Prescription Requirement: OTC products require an authorized prescription or clinical order connecting the medication to the work injury.
• Standard Supply: Prescribed OTC products may be dispensed according to the physician's order and applicable supply limitations.
• Pricing: OTC products are processed through the prescription pricing structure, using AWP × 0.90 for the ingredient component and the applicable $5.50 generic dispensing fee.
• Retrospective Review: The carrier may later review an OTC claim and deny products that are excessive or unrelated to the accepted injury.

Sources: Mich. Admin. Code R. 418.101003a(1); Michigan Workers' Disability Compensation Agency rules; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• 30-Day Limit: Commercial topical products dispensed at retail are limited to a maximum 30-day supply per transaction.
• Acquisition-Based Pricing: Applicable topical reimbursement is based on documented acquisition cost plus the authorized dispensing allowance rather than standard AWP markup.
• Dispensing Fee: One $8.50 dispensing fee may apply to a qualifying topical line, subject to the applicable frequency limitation.
• NDC Review: Repackager NDCs may be removed from the pricing calculation in favor of the original manufacturer's information.

Sources: Mich. Admin. Code R. 418.101003a(3); Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Ingredient-Level Billing: Each component of a compound must be reported separately with its quantity and applicable NDC.
• AWP Calculation: Ingredients are priced at AWP × 0.90, with total compound reimbursement limited to $600.
• Compounding Fee: One $10.00 compounding fee applies to the completed prescription.
• NDC Requirement: Original manufacturer or bulk supplier NDC information should be supplied for each component.
• Authorization: Custom compounds may require prospective authorization before dispensing.

Sources: Mich. Admin. Code R. 418.101003a(1); Michigan Workers' Disability Compensation Agency Fee Schedule Rules; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Properly coded pharmacy claims must be submitted within 365 days of dispensing under the stated Michigan framework.
• Payer Response: Carriers have 30 calendar days to pay or formally dispute a properly submitted claim.
• Interest: Eligible unpaid balances may accrue interest at 12% per year after the applicable payment deadline.
• Employee Protection: Injured workers are protected from direct collection efforts for disputed workers' compensation pharmacy charges.
• Dispute Process: Unresolved medical billing disputes may proceed through the Workers' Disability Compensation Agency using the applicable medical-dispute process.

Sources: MCL 418.315(4); Michigan Workers' Disability Compensation Agency Administrative Rules.

Pricing Source

• Red Book / Medi-Span AWP Master Database and manufacturer acquisition-cost information.

Sources: MCL 418.315; Mich. Admin. Code R. 418.101003a; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• Electronic Claims: Electronic retail pharmacy claims are limited to the lowest applicable amount among AWP × 0.88 plus a $3.65 dispensing fee, the state's Medicaid MAC amount plus $3.65, or the pharmacy's U&C price.
• Paper Claims: Paper transactions use a separate methodology based on the lower of 100% of AWP plus a $5.14 dispensing fee or the pharmacy's U&C charge.
• Two-Tier Dispensing Fees: Electronic transactions use the $3.65 allowance, while manual paper submissions use the $5.14 amount.
• Lesser-of Review: The final reimbursement is limited by the applicable fee schedule, market pricing, U&C amount, and any relevant contracted PBM rate.

Direct Care

• Yes: Minnesota permits certain employer-directed pharmacy arrangements. An employer may require an employee to use a pharmacy or pharmacy network when it meets the applicable statutory requirements, including the 15-mile residence-distance provision. Certified managed care arrangements may also affect pharmacy choice.

Sources: Minnesota Statutes 176.135, Subd. 1(f), (g), and (h); 176.1351; Minnesota Rules Part 5221.4070.

Pre-Authorization

• No: Electronic claims follow the AWP × 0.88 plus $3.65 structure, subject to the applicable reimbursement methodology and utilization review.

Source: Minn. Stat. 176.136 / DLI Pharmacy Rules.

OTC Restrictions

• Prescription Requirement: OTC products require a valid prescription or clinical order tying the product to the accepted injury.
• Electronic Pricing: Electronic OTC claims are limited to the lower of AWP × 0.88 plus $3.65 or the applicable Medicaid MAC amount plus $3.65.
• Paper Pricing: Paper submissions use the lower of 100% of AWP plus $5.14 or the pharmacy's U&C charge.
• Procedure Coding: OTC products do not require the same procedure-code structure used for legend drugs.
• Retrospective Review: Carriers may later review OTC claims and deny items found excessive or unrelated to the injury.

Sources: Minnesota Rules Part 5221.4070, Subparts 2–4; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Electronic Pricing: Electronic topical claims follow the lower of AWP × 0.88 plus $3.65, Medicaid MAC plus $3.65, or U&C.
• Paper Pricing: Paper claims are evaluated using the lower of 100% of AWP plus $5.14 or U&C.
• NDC Verification: Repackaged topical products may be checked against the original manufacturer's pricing information.
• Specialty Review: Higher-cost topicals may trigger utilization review and require medical-necessity documentation.
• Refills: Continued topical therapy may require updated clinical documentation.

Sources: Minnesota Rules Part 5221.4070, Subparts 3 & 4; Part 5221.6105; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Separate Components: Compound ingredients must be reported individually with quantities and NDC information.
• Electronic Formula: Each ingredient follows the applicable electronic pricing methodology of AWP × 0.88 plus $3.65, Medicaid MAC plus $3.65, or U&C, whichever is lower.
• Paper Formula: Paper components use the lower of 100% of AWP plus $5.14 or U&C.
• Single Fee: Only one dispensing fee applies to the completed compound.
• NDC Requirement: Original manufacturer or bulk supplier NDC information is required for each component.
• Authorization: Compounds may be subject to prospective utilization review and authorization.

Sources: Minnesota Rules Part 5221.4070, Subparts 3 & 4; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should be submitted within 365 days of dispensing under the stated Minnesota framework.
• Payer Review: The carrier has 30 calendar days to pay or deny a properly submitted bill.
• Late Interest: Eligible overdue amounts may accrue statutory interest under Minnesota law.
• Employee Protection: Workers are protected from balance billing for covered workers' compensation pharmacy services.
• Dispute Process: Unresolved pharmacy disputes may be submitted through the Minnesota Department of Labor and Industry's medical-dispute process.

Sources: Minnesota Statutes 176.135, Subd. 6; 176.136, Subd. 2; 176.221, Subd. 8; Minnesota Rules Part 5221.0700.

Pricing Source

• Red Book / Medi-Span AWP Database and Minnesota Department of Human Services pricing references.

Sources: Minnesota Rules Part 5221.4070; Minnesota Statutes 176.135 & 176.136; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• Brand Formula: Single-source brand medications are reimbursed at AWP plus a $5.00 professional dispensing fee.
• Generic Formula: Multi-source generic prescriptions are reimbursed at AWP × 0.95 plus a $5.00 professional dispensing fee.
• Lesser-of Review: Unless another applicable network agreement controls, reimbursement is limited to the lower of the pharmacy's billed charge or the applicable fee-schedule amount.
• NDC Requirement: Repackaged and physician-dispensed products are traced back to the original labeler NDC. Physician-dispensed products do not receive the retail dispensing fee.

Sources: Mississippi Workers' Compensation Commission Medical Fee Schedule Manual; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• No: Mississippi generally protects an injured worker's ability to select a treating physician and applicable referral provider. The same employee-choice principle extends to pharmacy selection, subject to applicable claim requirements.

Sources: Mississippi Code Annotated 71-3-15(1); Mississippi Administrative Code Title 20, Part 2, Chapter 3.

Pre-Authorization

• No: Mississippi's updated fee schedule incorporates revised generic pricing and other pharmacy reimbursement changes.

Source: Miss. Code Ann. 71-3-15 / MWCC Fee Schedule.

OTC Restrictions

• Prescription Requirement: OTC products require an authorized prescription or clinical order linking the medication to the work injury.
• Pricing: Prescribed OTC products are treated under the generic pharmacy methodology of AWP × 0.95 plus the $5.00 dispensing fee.
• Compound Treatment: A standalone OTC product follows the standard retail calculation, while an OTC ingredient used in a compound is handled under the compound methodology.
• Retrospective Review: Carriers may review OTC claims after dispensing and deny items that are not medically necessary or related to the accepted injury.

Sources: Mississippi Administrative Code Title 20, Part 2, Chapter 4; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Commercial Topicals: Brand topical products use the AWP plus $5.00 calculation, while generic topicals use AWP × 0.95 plus $5.00.
• OTC Topical Limits: Certain non-standard OTC topical products are subject to additional reimbursement ceilings, including $30 for creams and lotions and $75 for patches over a 30-day supply, prorated where applicable.
• NDC Review: Repackaged topical products are checked against the original manufacturer's information.
• Specialty Review: Higher-cost topical products may require medical-necessity documentation and prospective authorization.

Sources: Mississippi Administrative Code Title 20, Part 2, Chapter 4; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Component Billing: Each ingredient must be individually identified with the applicable quantity and NDC.
• Ingredient Pricing: Brand components are limited to AWP, while generic components are limited to AWP × 0.95.
• Single Dispensing Fee: One $5.00 professional dispensing fee applies to the finished compound.
• Topical Compound Cap: Retail topical compounds are limited to the lesser of $200 for a 30-day supply, prorated as appropriate, or the amount otherwise permitted under the fee schedule.
• Authorization: Custom compounds may be subject to prospective carrier authorization.

Sources: Mississippi Administrative Code Title 20, Part 2, Chapter 4; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Properly coded pharmacy claims should be submitted within 180 days of dispensing under the stated Mississippi framework.
• Payer Response: Carriers have 30 calendar days to pay or formally deny a properly submitted bill.
• Late Interest: Eligible unpaid balances may accrue interest at 10% per year after the applicable payment period.
• Employee Protection: Workers are protected from balance billing during pharmacy payment disputes.
• Dispute Process: Unresolved disputes may proceed through the Mississippi Workers' Compensation Commission using the applicable medical dispute process.

Sources: Mississippi Code Annotated 71-3-15; Mississippi Workers' Compensation Commission General Rules.

Pricing Source

• Red Book / Medi-Span AWP Master Database.

Sources: Mississippi Code Annotated 71-3-15; 20 Miss. Code R. 2-IV; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• No Dedicated Pharmacy Grid: Missouri does not use a separate formulaic workers' compensation pharmacy fee schedule for prescription medications under the stated framework.
• Brand Pricing: Brand prescriptions are generally evaluated using the pharmacy's submitted U&C charge.
• Generic Pricing: Generic prescriptions are likewise based on the pharmacy's U&C pricing.
• Fair and Reasonable Review: Pharmacy charges remain subject to review for reasonableness and comparison with prevailing community pricing.
• Physician-Dispensed Products: Missouri does not establish a separate state formula for physician-dispensed or repackaged medications under the stated framework.

Sources: Missouri Revised Statutes 287.140; 8 CSR 50-2.030; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Yes: Missouri operates under an employer-directed care model. The employer or carrier may select treating physicians, specialists, medical networks, and applicable pharmacy providers under the workers' compensation system.

Source: Missouri Revised Statutes 287.140.1.

Pre-Authorization

• No: Pharmacy claims generally operate through the carrier's formulary and PBM utilization procedures, including applicable generic-substitution and utilization controls.

Source: Mo. Rev. Stat. 287.140 / Division of Workers' Compensation.

OTC Restrictions

• Prescription Requirement: OTC medications require a valid prescription or clinical order establishing a connection to the accepted workplace injury.
• U&C Pricing: Prescribed OTC products are reimbursed using the pharmacy's U&C rate, subject to reasonable and prevailing community pricing.
• No Separate Dispensing Fee: Missouri does not establish a separate formulaic retail dispensing fee for standard OTC transactions under the stated framework.
• Retrospective Review: The carrier may later review the transaction and deny products that are excessive or unrelated to the compensable injury.

Sources: Missouri Revised Statutes 287.140; 8 CSR 50-2.030; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• No Dedicated Topical Formula: Missouri does not establish a separate state pricing grid or quantity formula specifically for standalone topical medications.
• U&C Pricing: Commercial topicals are generally reimbursed using the pharmacy's U&C charge, subject to fair and reasonable pricing review.
• NDC Review: Repackaged topical products may be compared against the original manufacturer's pricing information.
• Specialty Products: High-cost topicals may be subject to utilization review and medical-necessity requirements.

Sources: Missouri Revised Statutes 287.140; 8 CSR 50-2.030; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Component Reporting: Compound prescriptions must identify each ingredient separately, including quantity and NDC information.
• U&C Pricing: Individual components are evaluated using applicable U&C pricing rather than a dedicated state compound formula.
• Handling Fees: Multiple compounding or handling fees cannot be added to the same prescription.
• NDC Verification: Missing, invalid, or unsupported NDC information may result in rejection or a $0.00 allowance for the affected component.
• Authorization: Custom compounds may be subject to carrier utilization review and prospective authorization.

Sources: Missouri Revised Statutes 287.140; 8 CSR 50-2.030; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should be submitted within 365 days of dispensing under the stated Missouri framework. Late submissions may face administrative review or denial.
• Payer Response: The employer or carrier has a 30-day processing period to pay or formally dispute a properly submitted claim.
• Employee Protection: Injured workers are protected from direct collection of covered pharmacy balances during an active workers' compensation dispute.
• Dispute Process: Pharmacy providers contesting reimbursement may use the Missouri Division of Workers' Compensation medical-fee dispute process.

Sources: Missouri Revised Statutes 287.140.13; 8 CSR 50-2.030.

Pricing Source

• Pharmacy U&C Retail Pricing Profile and Regional Cash-Market Index.

Sources: Missouri Revised Statutes 287.140; Missouri Code of State Regulations, Title 8, Division 50; Clinic Meds Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• AWP-Based Retail Pricing: Montana uses the Average Wholesale Price (AWP) as the starting point for pricing outpatient prescriptions dispensed through licensed retail pharmacies.
• Brand-Name Drugs: Single-source brand medications are reimbursed at up to 90% of AWP plus a $3.00 dispensing fee.
• Generic Drugs: Multi-source generic medications are reimbursed at up to 75% of AWP plus a $3.00 dispensing fee.
• Lesser-of Pricing: The final reimbursement is limited to the lower of the applicable state fee schedule amount or the pharmacy's submitted Usual & Customary (U&C) charge.
• Physician Dispensing: Physician dispensing is permitted only under specific statutory exceptions, with no separate alternative pricing methodology identified for those exceptions.

Sources: Administrative Rules of Montana (ARM) 24.29.1517; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• No: Montana generally allows the injured employee to select the initial treating physician under MCA 39-71-704. An employer or insurer cannot require the worker to use a particular physician for the initial course of treatment.
• After the initial encounter, MCA 39-71-315 allows an employer or insurer participating in an approved MCO or PPO arrangement to direct the worker to another primary treating physician.

Sources: Montana Code Annotated (MCA) 39-71-315 and 39-71-704; Administrative Rules of Montana (ARM) 24.29.1517.

Pre-Authorization

• Yes: Montana uses the ODG Drug Formulary. Medications classified as non-preferred or "N" generally require prospective payer authorization before dispensing.

Source: Mont. Code Ann. 39-71-704 / DLI Rules.

OTC Restrictions

• Prescription Requirement: OTC medications must have a valid written prescription or clinical order from the authorized treating physician and must be related to the accepted workplace injury to qualify for reimbursement.
• Retail Pricing: Prescribed OTC products are processed under the state's retail prescription pricing structure, with ingredient reimbursement generally following the generic formula of 75% of AWP plus the $3.00 dispensing fee.
• Compound Treatment: An OTC product billed independently is subject to the applicable retail rules. When an OTC ingredient becomes part of a compounded prescription, the completed compound is subject to Montana's compound billing requirements.
• Retrospective Review: Routine OTC prescriptions may be dispensed without prospective authorization, but the carrier can later review the charge and deny reimbursement when the product is found excessive or unrelated to the compensable injury.

Sources: Administrative Rules of Montana (ARM) 24.29.1517; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Standard Retail Pricing: Commercial prescription creams, ointments, gels, and transdermal products follow Montana's standard retail pricing methodology. Brand products use the brand formula, while generics use the generic formula.
• NDC Verification: Repackaged topical products may be reviewed against the original manufacturer's NDC and pricing information to prevent inflated reimbursement.
• Specialty Topicals: Higher-cost patches and specialty topical medications may be subject to utilization review and prospective authorization when clinical documentation is required.
• Refill Review: Continued topical treatment may be reviewed for medical necessity. Additional refills may require updated documentation from the treating physician.

Sources: Administrative Rules of Montana (ARM) 24.29.1517; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Itemized Billing: Each ingredient in a compounded prescription should be reported separately, including the ingredient quantity and applicable NDC.
• Ingredient Pricing: Brand ingredients are subject to the brand AWP methodology, while generic ingredients follow the generic AWP methodology. Invalid or unusable NDC information may result in the ingredient being excluded from reimbursement.
• Single Dispensing Fee: Montana limits the retail transaction to one $3.00 dispensing fee rather than separate fees for each ingredient.
• Manufacturer NDC: Original manufacturer or bulk supplier NDC information should be supplied for each ingredient. Repackager NDCs may trigger billing edits.
• Prior Authorization: Compounded prescriptions may be subject to prospective authorization before the pharmacy can obtain payment approval.

Sources: Administrative Rules of Montana (ARM) 24.29.1517; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Pharmacy Billing Deadline: Properly submitted pharmacy claims should be filed within 365 days of dispensing under Montana workers' compensation billing requirements.
• Payer Response Period: The employer or insurer generally has 30 days after receiving a properly documented bill to pay or deny the charge.
• Employee Protection: During a billing dispute, the injured employee should not be responsible for disputed workers' compensation pharmacy charges.
• Dispute Resolution: Unresolved payment disputes may be taken through the Montana Department of Labor and Industry's applicable medical dispute process before further court proceedings.

Sources: Montana Code Annotated (MCA) 39-71-704; Administrative Rules of Montana (ARM) 24.29.1513.

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: Montana Code Annotated (MCA) 39-71-704; Administrative Rules of Montana (ARM) Title 24, Chapter 29; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• No Fixed Pharmacy Formula: Nebraska does not establish a percentage-based workers' compensation pharmacy fee schedule for retail prescriptions.
• Brand Medications: Reimbursement is generally based on the pharmacy's actual submitted charge or another reasonable rate.
• Generic Medications: Generic prescriptions are likewise evaluated using the pharmacy's actual charge and applicable reasonableness standards.
• Reasonable Charge Review: A payer may challenge a billed amount when evidence indicates that the charge exceeds the customary rate for comparable services in the same geographic area.
• Physician Dispensing: The retail pharmacy pricing framework does not establish a separate methodology for physician-dispensed or repackaged medications.

Sources: Nebraska Workers' Compensation Court Schedule of Fees; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Yes: Nebraska generally gives the employer or workers' compensation carrier the initial authority to select the treating physician under Neb. Rev. Stat. 48-120(2).
• An exception may apply when an injured employee has an established treatment relationship with a physician before the injury and properly notifies the employer of that relationship.

Sources: Nebraska Revised Statutes 48-120(2) and (6); Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Pre-Authorization

• No: Nebraska does not impose a state pharmacy formulary requiring blanket prospective authorization. Carrier PBM programs may still apply utilization controls, including opioid-duration and generic-use requirements.

Source: Neb. Rev. Stat. 48-120 / Workers' Comp Court.

OTC Restrictions

• Prescription Requirement: An OTC medication generally needs a valid physician prescription or clinical order connecting the product to the compensable workplace injury.
• Reasonable Pricing: Prescribed OTC products are evaluated against the pharmacy's actual charge and Nebraska's reasonable-charge standard rather than a fixed AWP formula.
• Dispensing Fee: Nebraska does not establish a separate formulaic dispensing allowance for these OTC transactions.
• Retrospective Review: Carriers may review an OTC charge after dispensing and deny payment when the product is excessive or not medically related to the injury.

Sources: Nebraska Revised Statutes 48-120; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Actual Charge Basis: Commercial topical medications are generally evaluated using the pharmacy's submitted charge, subject to Nebraska's reasonable-charge requirements.
• NDC Review: Repackaged topical products may be reviewed against original manufacturer information to establish an appropriate pricing basis.
• Specialty Products: High-cost topical medications, including specialty patches and gels, may trigger utilization review and requests for medical-necessity documentation.
• Refill Oversight: Continued topical therapy may be reviewed to confirm that ongoing treatment remains medically necessary.

Sources: Nebraska Workers' Compensation Court Rules of Procedure; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Ingredient-Level Billing: Each component of a compound should be separately identified with its quantity and applicable NDC.
• Reasonable Pricing: Compound ingredients are evaluated according to the pharmacy's submitted charge and Nebraska's reasonable-value standards.
• No Stacked Fees: Multiple compounding or handling charges are not supported by a formulaic Nebraska pharmacy fee schedule.
• Prior Authorization: Non-routine compounds may be subject to carrier or PBM authorization requirements before payment approval.

Sources: Nebraska Workers' Compensation Court Rules of Procedure; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should generally be submitted within 365 days of dispensing.
• Payer Response: The employer or insurer has a 30-day processing period after receiving a properly documented bill.
• Late Payment: Nebraska law provides for a 14% annual interest rate on qualifying unpaid amounts under Neb. Rev. Stat. 48-125.
• Employee Protection: The injured worker should not be balance billed for covered workers' compensation pharmacy services.
• Disputes: Unresolved pharmacy billing matters may be presented to the Nebraska Workers' Compensation Court.

Sources: Nebraska Revised Statutes 48-120 and 48-125; Nebraska Workers' Compensation Court Rules of Procedure.

Pricing Source

• Pharmacy Actual Billed Charges and Regular Charge Market Index

Sources: Nebraska Revised Statutes 48-120; Nebraska Workers' Compensation Court Rule 26; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• AWP-Based Pricing: Nevada's Medical Fee Schedule uses AWP as the foundation for retail pharmacy reimbursement.
• Retail Drug Formula: Brand-name and generic legend drugs are generally priced at AWP plus a $13.70 dispensing fee.
• Lesser-of Rule: The reimbursable amount is limited to the lowest applicable amount among the state fee schedule, submitted U&C charge, or contracted network rate.
• Inpatient Drugs: Medications provided during inpatient hospitalization are generally included within the hospital's facility reimbursement rather than separately billed as retail pharmacy transactions.

Sources: Nevada Revised Statutes (NRS) 616C.260; Nevada Medical Fee Schedule Pharmaceutical Guidelines; Nevada Division of Industrial Relations February 1, 2026 Update; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Yes: Nevada uses a structured medical-direction system. Where an employer or carrier operates through an approved MCO or PPO, treatment may be directed through that network.
• In applicable open-market arrangements, injured workers may use participating pharmacy locations within the carrier's designated PBM network.

Sources: Nevada Revised Statutes (NRS) 616C.090; Nevada Administrative Code Chapter 616C; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Pre-Authorization

• No: Nevada generally operates with an open formulary structure, with carrier PBM programs controlling utilization and generic substitution.

Source: NRS 616C.130 / Nevada DIR Administrative Rules.

OTC Restrictions

• Prescription Requirement: OTC medications require a valid prescription or clinical order linking the medication to the compensable injury.
• Pricing: Prescribed OTC products are subject to the applicable Nevada retail pricing methodology, including the AWP plus $13.70 baseline, U&C amount, or contracted rate, whichever is lower.
• Additional Charges: Separate compounding or custom handling charges are not permitted unless specifically supported by the applicable fee schedule.
• Inpatient Treatment: OTC medications provided during inpatient care are handled within the hospital's applicable facility reimbursement rather than the outpatient pharmacy schedule.

Sources: Nevada Medical Fee Schedule Pharmaceutical Guidelines; Nevada Division of Industrial Relations February 1, 2026 Rule Update; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Retail Pricing: Commercial topical products follow Nevada's standard retail pharmacy pricing methodology, subject to the applicable lesser-of calculation.
• NDC Validation: Repackaged topicals may be reviewed against the original manufacturer's NDC and AWP information.
• Prior Authorization: Higher-cost topical medications may require prospective authorization when they exceed applicable utilization or financial thresholds.
• Refill Monitoring: Continued topical treatment may require documentation confirming ongoing medical necessity.

Sources: Nevada Division of Industrial Relations Medical Fee Schedule Guidelines; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Detailed Ingredient Billing: Each compound ingredient should be separately reported with quantity and NDC information.
• Ingredient Cost: Compound ingredients are generally valued using 100% of applicable AWP.
• Topical Compound Limit: Under the February 1, 2026 fee schedule revisions, topical compounds are subject to a maximum reimbursement of $240 for a 30-day supply, prorated when applicable, or the applicable standard fee schedule amount, whichever is lower.
• Authorization: Custom compounds may require prior carrier authorization before dispensing.

Sources: Nevada Administrative Code Chapter 616C; Nevada Division of Industrial Relations Workers' Compensation Section February 2026 Fee Updates; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should be submitted within 90 days of dispensing.
• Payer Response: Under NRS 616C.136, the payer generally has 30 days after receiving a properly documented bill to pay or deny the charge.
• Late Payment: Qualifying unpaid amounts may accrue statutory interest after the payment deadline.
• Employee Protection: Covered workers' compensation pharmacy charges should not be billed directly to the injured worker. Violations may result in administrative penalties.
• Disputes: Unresolved pharmacy billing disputes may be submitted through the Workers' Compensation Section of Nevada's Division of Industrial Relations.

Sources: Nevada Revised Statutes 616C.135 and 616C.136; Nevada Administrative Code Chapter 616C; Division of Industrial Relations Workers' Compensation Section.

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: Nevada Revised Statutes 616C.260; Nevada Administrative Code Chapter 616C; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• No Fixed Pharmacy Schedule: New Hampshire does not publish a percentage-based pharmacy fee schedule specifically for workers' compensation prescriptions.
• Brand and Generic Drugs: Reimbursement is generally based on the reasonable value of the medication or service rather than a fixed AWP formula.
• Reasonableness Standard: A pharmacy must be able to support the reasonableness of its charges when challenged by the payer.
• Physician Dispensing: No separate pricing methodology is identified for physician-dispensed or repackaged medications within this retail framework.

Sources: New Hampshire Revised Statutes Annotated (RSA) 281-A:24, Subdivision I; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• No: RSA 281-A:23 gives an injured employee the right to choose a pharmacy or pharmacist for medications required under workers' compensation.

Sources: New Hampshire Revised Statutes Annotated 281-A:23 and 281-A:23-a; Workers' Compensation Fact Sheet; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Pre-Authorization

• No: New Hampshire does not operate under a state-mandated workers' compensation pharmacy fee schedule or formulary. Reimbursement is based on reasonable value.

Source: RSA Chapter 281-A / Department of Labor.

OTC Restrictions

• Prescription Requirement: OTC medications need a valid physician prescription or clinical order tying the product to the compensable injury.
• Generic Substitution: Applicable generic substitution requirements may extend to OTC prescriptions unless the practitioner documents medical necessity for a particular product.
• Reasonable Value: Reimbursement is based on reasonable value rather than a fixed AWP percentage.
• Retrospective Review: The carrier may later review the charge and deny an OTC item determined to be excessive or unrelated to the workplace injury.

Sources: New Hampshire Revised Statutes Annotated 281-A:23(I) and 281-A:24(II); Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Reasonable Value Pricing: Commercial topical prescriptions are evaluated under New Hampshire's reasonable-value standard.
• NDC Review: Repackaged products may be compared with original manufacturer information when determining an appropriate reimbursement basis.
• Specialty Topicals: Higher-cost topical products may receive additional utilization review and require supporting medical-necessity documentation.
• Refill Review: Continued topical treatment may be reviewed to verify ongoing medical necessity.

Sources: New Hampshire Revised Statutes Annotated 281-A:24(I) and (II); Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Ingredient Detail: Compounded prescriptions should identify each ingredient, quantity, and applicable NDC separately.
• Reasonable Charge: Compound ingredients are evaluated under the provider's submitted charge and the state's overall reasonable-value standard.
• Fee Limits: Multiple compounding or laboratory handling fees are not supported by a fixed state pharmacy fee schedule.
• Authorization: Non-routine compounds may be subject to carrier authorization requirements.

Sources: New Hampshire Revised Statutes Annotated 281-A:24(I); Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should generally be submitted within 365 days of dispensing.
• Payer Response: The employer or carrier generally has 30 days after receiving a properly documented bill to respond.
• Dispute Resolution: Providers should first attempt to resolve reasonable-value billing disputes directly with the carrier.
• Employee Protection: The injured worker should not be billed directly for covered workers' compensation pharmacy services.
• Formal Review: Unresolved disputes may be submitted to the New Hampshire Department of Labor for administrative review.

Sources: New Hampshire Revised Statutes Annotated 281-A:24(I); Workers' Compensation Fact Sheet.

Pricing Source

• Pharmacy Actual Billed Charges and Regional Retail Cash Index

Sources: New Hampshire Revised Statutes Annotated 281-A:24; New Hampshire Department of Labor; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• No Dedicated Pharmacy Fee Schedule: New Jersey does not establish a separate pharmacy fee schedule for workers' compensation prescriptions.
• Brand and Generic Pricing: Retail pharmacy reimbursement is generally based on the pharmacy's Usual & Customary (U&C) charge.
• Community Reasonableness: Charges remain subject to review against prevailing rates for comparable services in the local market.
• Physician Dispensing: Physician-dispensed medications may be subject to separate statutory restrictions, while traditional retail pharmacies are not subject to the same dispensing limitations.

Sources: New Jersey Statutory Amendments Annotated (N.J.S.A.) 34:15-15; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Yes: New Jersey generally gives the employer or carrier control over selection of treating providers and applicable medical networks under N.J.S.A. 34:15-15.

Sources: New Jersey Statutory Amendments Annotated (N.J.S.A.) 34:15-15; New Jersey Department of Labor and Workforce Development Employer Rights Overview.

Pre-Authorization

• No: New Jersey does not use a state-controlled pharmacy fee schedule for these prescriptions. Reimbursement is generally based on the provider's usual and customary charge.

Source: N.J. Stat. Ann. 34:15-15 / Department of Labor.

OTC Restrictions

• Prescription Requirement: OTC products need an authorized prescription or clinical order establishing their relationship to the workplace injury.
• U&C Pricing: Prescribed OTC products are evaluated using the pharmacy's U&C charge, subject to prevailing community pricing standards.
• Additional Fees: No separate formulaic dispensing surcharge is established for basic OTC transactions.
• Retrospective Review: Carriers may review OTC charges after dispensing and deny products that are excessive or unrelated to the compensable injury.

Sources: New Jersey Statutory Amendments Annotated (N.J.S.A.) 34:15-15; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• No Separate Topical Schedule: New Jersey does not establish a dedicated topical pricing schedule or separate topical reimbursement cap within this framework.
• U&C Pricing: Commercial topical medications are generally evaluated using the pharmacy's U&C charge and applicable community reasonableness standards.
• NDC Verification: Repackaged topical products may be reviewed against original manufacturer information.
• Specialty Review: High-cost topical products may be subject to utilization review and medical-necessity requirements.

Sources: New Jersey Statutory Amendments Annotated (N.J.S.A.) 34:15-15; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Detailed Billing: Each compound ingredient should be separately identified with its quantity and NDC.
• No Dedicated Compound Schedule: New Jersey does not establish a separate state compound pricing structure or specialized compound reimbursement cap within this framework.
• U&C Pricing: Individual ingredients are evaluated using the pharmacy's U&C rate, subject to applicable community reasonableness standards.
• Additional Fees: Multiple compounding or laboratory fees are not supported by a formulaic state pharmacy schedule.
• Authorization: Custom compounds may require carrier or PBM authorization before payment.

Sources: New Jersey Statutory Amendments Annotated (N.J.S.A.) 34:15-15; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should generally be submitted within 365 days of dispensing.
• Payer Response: The employer or carrier generally has 60 days after receiving a properly documented pharmacy bill to pay or deny the charge.
• Employee Protection: Covered workers' compensation pharmacy services should not be balance billed to the injured employee.
• Dispute Deadline: A pharmacy seeking payment through the New Jersey Division of Workers' Compensation generally has a 6-year period under N.J.S.A. 34:15-51, subject to the applicable statutory requirements.

Sources: New Jersey Statutory Amendments Annotated (N.J.S.A.) 34:15-15 and 34:15-51; NJ Division of Workers' Compensation Medical Provider Claims Manual.

Pricing Source

• Pharmacy U&C Retail Master Profile and Regional Cash Index

Sources: New Jersey Statutory Amendments Annotated (N.J.S.A.) Title 34, Chapter 15; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• AWP-Based Retail Pricing: New Mexico uses AWP as the primary reference for outpatient prescriptions filled through licensed retail pharmacies.
• Brand Medications: Single-source brand or trade-name medications are reimbursed at up to AWP plus $4.00.
• Generic Medications: Multi-source generic prescriptions follow the same AWP plus $4.00 calculation.
• WAC Alternative: When an applicable AWP is unavailable, the pricing methodology may use 120% of Wholesale Acquisition Cost (WAC) as the alternative basis.
• Lesser-of Calculation: Reimbursement is limited to the lowest applicable amount among the state fee schedule, pharmacy U&C charge, or contracted network rate.

Sources: New Mexico Administrative Code (NMAC) Title 11, Chapter 4, Part 7; New Mexico Workers' Compensation Administration 2026 Provider Fee Schedule Manual; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Shared Selection: New Mexico provides a dual-selection structure under NMSA 1978, 52-1-49, allowing either the employer or employee to make the initial treating-physician selection.

Sources: New Mexico Statutes Annotated 1978, 52-1-49; New Mexico Administrative Code 11.4.7 NMAC; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Pre-Authorization

• Yes: New Mexico uses the ODG Appendix A Drug Formulary. Medications designated with an "N" status may require authorization before dispensing.

Source: N.M. Stat. Ann. 52-4-1 / WCA Administrative Rules.

OTC Restrictions

• Prescription Requirement: OTC medications must be supported by a valid prescription or clinical order connecting the product to the accepted workplace injury.
• Retail Pricing: Prescribed OTC products follow the state's standard retail pricing structure, based on AWP plus the $4.00 dispensing fee.
• Compound Treatment: An OTC item billed separately follows the retail prescription methodology. OTC ingredients incorporated into a compound are subject to the compound rules.
• Retrospective Review: Carriers may review dispensed OTC products after the transaction and deny items determined to be unnecessary or unrelated to the compensable injury.

Sources: New Mexico Administrative Code 11.4.7 NMAC; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Standard Pricing: Commercial topical prescriptions generally follow the New Mexico retail formula of AWP plus $4.00.
• OTC Topical Limits: Under the referenced 2026 parameters, topical creams and ointments excluding patches are limited to $31.21 per 30-day supply, while transdermal patches are limited to $72.83 per 30-day supply, prorated when applicable.
• NDC Review: Repackaged topicals may be evaluated against original manufacturer data.
• Topical Compounds: Customized prescription topical compounds are subject to a maximum reimbursement of $200 per 30-day supply, prorated as appropriate, or the applicable fee schedule amount, whichever is lower.
• Specialty Products: High-cost topical medications may require medical-necessity documentation or prospective authorization.

Sources: New Mexico Administrative Code 11.4.7 NMAC; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Ingredient-Level Billing: Compound prescriptions should identify each ingredient separately, including quantity and NDC information.
• Compound Pricing: Ingredients are priced under the applicable compound methodology, with brand and generic components subject to the specified AWP-based calculation.
• Original NDC Requirement: Original manufacturer or bulk supplier NDC information should be supplied for each compound ingredient. Repackager NDCs may trigger billing edits.
• Authorization: Custom compounds may require prospective authorization before dispensing.

Sources: New Mexico Workers' Compensation Administration 2026 Provider Fee Schedule Manual and Billing Instructions; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should be submitted within 90 days of dispensing.
• Payer Response: The employer or insurer generally has 30 days after receiving a properly documented bill to pay or deny the charge.
• Employee Protection: The injured employee should not be billed directly for covered workers' compensation pharmacy services.
• Disputes: Billing disputes may be addressed through the New Mexico Workers' Compensation Administration's applicable dispute-resolution process, including the stated 90-day filing period for qualifying partial payments or denials.

Sources: New Mexico Administrative Code 11.4.7 NMAC.

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: New Mexico Administrative Code 11.4.7 NMAC; NMSA 1978, 52-4-5; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• AWP-Based Retail Formula: New York calculates retail pharmacy reimbursement using AWP-based pricing under its workers' compensation pharmacy rules.
• Brand Medications: Single-source brand prescriptions are calculated at 88% of AWP plus a $4.00 dispensing fee.
• Generic Medications: Multi-source generics are calculated at 80% of AWP plus a $5.00 dispensing fee.
• Lesser-of Rule: The final amount is limited to the lowest applicable fee schedule calculation, submitted U&C charge, or contracted rate.
• Inpatient Medications: Drugs provided during inpatient hospitalization are generally incorporated into the facility reimbursement rather than separately billed through the outpatient pharmacy schedule.

Sources: 12 NYCRR 440.2; New York State Workers' Compensation Board Subject Number 046-502; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• No: When an employer has an authorized PBM arrangement, the worker generally must use a participating pharmacy within the designated network, subject to applicable New York workers' compensation pharmacy rules.

Sources: New York Workers' Compensation Law 13-a and 13-p; 12 NYCRR 440.3.

Pre-Authorization

• Yes: New York uses the Workers' Compensation Board Drug Formulary, which includes Phase A, Phase B, and perioperative classifications. Non-formulary medications may require a formal Prior Authorization Request through the Medical Portal.

Source: 12 NYCRR 441.2 / New York WCB Drug Formulary.

OTC Restrictions

• Prescription Requirement: OTC medications require a valid prescription or clinical order linking the medication to the accepted workplace injury.
• PBM Processing: Eligible OTC prescriptions must be processed through the appropriate electronic pharmacy or PBM system.
• Generic Pricing: Where applicable, generic OTC prescriptions follow the state's generic calculation of 80% of AWP plus the $5.00 dispensing fee.
• Lowest-Cost NDC: When equivalent generic products are available, reimbursement may be limited to the applicable lowest-cost generic NDC.

Sources: 12 NYCRR 440.2; New York State Workers' Compensation Board Pharmacy Fee Schedule Manual; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Standard Pricing: Commercial topicals follow the applicable New York retail formulas, with brand products calculated at 88% of AWP plus $4.00 and generics at 80% of AWP plus $5.00.
• OTC Topical Limits: Referenced 2026 parameters limit topical creams and ointments excluding patches to $31.21 per 30-day supply and transdermal patches to $72.83 per 30-day supply, prorated where appropriate.
• NDC Validation: Repackaged topical products may be reviewed against original manufacturer data.
• MTG Compliance: Topical medications are also evaluated against New York Medical Treatment Guidelines for appropriate frequency, duration, and clinical use.

Sources: New York State Workers' Compensation Board Medical Treatment Guidelines; 12 NYCRR Part 440; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Detailed Ingredient Reporting: Each ingredient in a compound should be separately identified with its quantity and NDC.
• Ingredient Pricing: Brand components follow the 88% AWP calculation, while generic components follow the 80% AWP calculation.
• Fee Limitation: Multiple dispensing or compounding fees cannot be stacked for individual ingredients.
• Prior Authorization: Custom compounds may require authorization through the Workers' Compensation Board Medical Portal before payment approval.

Sources: 12 NYCRR Part 440; New York State Workers' Compensation Board Drug Formulary Compounding Rules; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should generally be submitted within 120 days of dispensing.
• Payer Payment Window: Qualifying pharmacy bills are generally subject to a 45-day payment period under WCL 13-g.
• Disputed Bills: When a pharmacy bill is contested, the payer must provide written notice explaining the dispute within the applicable timeframe.
• Employee Protection: Participating pharmacies must follow applicable fee schedule requirements and cannot balance bill the injured employee for covered workers' compensation services.
• Disputes: Providers may use Form HP-1 to pursue arbitration of eligible medical billing disputes through the New York Workers' Compensation Board.

Sources: New York Workers' Compensation Law 13-g; 12 NYCRR 325-1.25; WCB Pharmacy Benefit Management Questions and Answers Guide.

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: 12 NYCRR Part 440; New York Workers' Compensation Law 13-o; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

State Fee Schedule

• AWP-Based Uniform Formula: North Carolina applies a common AWP-based reimbursement formula to brand and generic prescriptions dispensed through retail pharmacies.
• Brand Drugs: Single-source brand medications are reimbursed at up to 95% of AWP.
• Generic Drugs: Multi-source generic medications are also reimbursed at up to 95% of AWP.
• No Separate Dispensing Fee: The referenced statutory framework does not provide a separate professional dispensing fee for these retail transactions.
• Lesser-of Rule: Final reimbursement is limited to the lower of the applicable 95% AWP amount, the pharmacy's U&C charge, or a contracted network rate.

Sources: N.C. Gen. Stat. 97-26.2(a); North Carolina Industrial Commission Fee Schedule Manual; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Direct Care

• Yes: North Carolina generally gives the employer or carrier authority to direct medical treatment under N.C. Gen. Stat. 97-25, including applicable provider and pharmacy networks.

Sources: N.C. Gen. Stat. 97-25; North Carolina Industrial Commission Rules for Managed Care; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Pre-Authorization

• No: North Carolina follows an open formulary structure under the Industrial Commission, with generic substitution requirements for applicable multi-source medications.

Source: N.C. Gen. Stat. 97-26 / Industrial Commission.

OTC Restrictions

• Prescription Requirement: OTC medications require an authorized prescription or clinical order connecting the product to the compensable workplace injury.
• Pricing: Prescribed OTC products are reimbursed using the applicable 95% AWP calculation.
• No Handling Surcharge: The referenced statutory framework does not provide an additional professional handling fee for standalone OTC transactions.
• Retrospective Review: Carriers may later review the medical necessity and relationship of the OTC medication to the workplace injury.

Sources: N.C. Gen. Stat. 97-26.2(a); Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Topical Restrictions

• Standard Pricing: Commercial topical medications generally follow the North Carolina retail formula of 95% of AWP.
• NDC Verification: Repackaged topical products may be reviewed against original manufacturer information.
• Specialty Topicals: Higher-cost patches and specialty gels may receive utilization review and require supporting medical-necessity documentation.
• Refill Monitoring: Continued topical treatment may be reviewed to verify ongoing medical necessity.

Sources: N.C. Gen. Stat. 97-26.2(a); North Carolina Industrial Commission Medical Fee Schedule Guidelines; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Compound Restrictions

• Ingredient-Level Billing: Each compound ingredient should be separately reported with its quantity and NDC.
• Ingredient Pricing: Active compound ingredients are subject to the 95% AWP pricing methodology.
• Handling Fees: Retail pharmacies may not stack multiple compounding or preparation charges for individual components. Any applicable single compounding fee remains subject to the governing reimbursement rules.
• Authorization: Custom compounds may require prospective authorization through the carrier or PBM.

Sources: N.C. Gen. Stat. 97-26.2(a); Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

• Billing Deadline: Pharmacy claims should generally be submitted within 180 days of dispensing under the referenced North Carolina Industrial Commission requirements.
• Payer Response: The employer or carrier generally has 60 days after receiving a properly documented bill to pay or deny the charge.
• Late Payment: Qualifying unpaid amounts may accrue 10% annual interest after the applicable payment period.
• Employee Protection: Covered workers' compensation pharmacy charges should not be collected directly from the injured employee.
• Disputes: Unresolved matters may be submitted to the North Carolina Industrial Commission through the applicable hearing process, including Form I.C. 33 where appropriate.

Sources: N.C. Gen. Stat. 97-18(i) and 97-26; 11 NCAC 23J .0102.

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: N.C. Gen. Stat. 97-26.2; North Carolina Administrative Code Title 11, Chapter 23J; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Clinic Meds can use this state-by-state information as a general reference for workers' compensation pharmacy billing, pricing, authorization, and reimbursement considerations.

State Fee Schedule

North Dakota workers' compensation pharmacy reimbursement uses WAC-based pricing for retail prescriptions. Brand-name medications are generally reimbursed at WAC × 1.08 + $4.00, while generic medications are subject to the applicable WAC or MAC pricing methodology, plus the dispensing fee.

Final reimbursement may also be limited by the pharmacy's Usual and Customary (U&C) price or a contracted network rate, whichever is lower.

Direct Care

Yes. North Dakota operates through Workforce Safety & Insurance (WSI), which has authority over medical care and treatment within the workers' compensation system.

Pre-Authorization

Yes. Certain medications, including nonpreferred drugs, specialty medications, and compounds, may require prior authorization before dispensing.

OTC Restrictions

OTC medications generally require a valid prescription or clinical order connected to the accepted workplace injury. Approved OTC prescriptions must be processed through the applicable electronic pharmacy billing system and are subject to the state's reimbursement rules.

Topical Restrictions

Commercial topical medications are generally reimbursed under the applicable WAC-based pricing methodology. Compounded topical medications may be subject to ingredient-specific strength limits, quantity restrictions, diagnostic requirements, and other utilization controls.

Compound Restrictions

Compounded medications are subject to ingredient, strength, quantity, and reimbursement limits. Compounds may be limited to five active ingredients and a 30% combined strength, with quantity limits based on the duration of therapy.

Approved compounds use an AWP-based reimbursement methodology and may qualify for a tiered compounding labor fee. Prior authorization through the applicable WSI process is required.

Timelines

Pharmacy bills should generally be submitted within 1 year of the date of service. WSI generally has 30 days to process a properly documented bill. Providers may use the applicable reconsideration or dispute process when a payment or claim is denied.

Pricing Source

Wolters Kluwer Medi-Span Electronic Drug File and WSI MAC Register.

State Fee Schedule

Ohio workers' compensation pharmacy reimbursement uses the published AWP for prescription medications. Brand-name medications are generally reimbursed at AWP × 0.85 + $3.50, while generic medications are subject to the applicable AWP or MAC pricing, whichever produces the lower reimbursement.

Final payment may also be limited by the pharmacy's U&C price or a contracted network rate.

Direct Care

Yes. Ohio workers' compensation medical care may be managed through the employer's designated Managed Care Organization (MCO), which oversees provider networks and treatment authorization.

Pre-Authorization

Yes. Ohio BWC uses an outpatient drug formulary. Medications outside the allowed formulary may require prior authorization.

OTC Restrictions

OTC medications generally require a valid prescription or clinical order related to the allowed workplace injury. Approved OTC prescriptions must be submitted through the appropriate electronic pharmacy billing process and are subject to applicable reimbursement limits.

Topical Restrictions

Commercial topical medications are generally reimbursed under the state's standard pharmacy pricing methodology. Certain topical medications may be subject to quantity limits, formulary restrictions, or prior authorization requirements.

Repackaged products may also be subject to NDC and pricing verification.

Compound Restrictions

Compounded medications must be billed by individual ingredient and include the applicable NDC information. Ingredient reimbursement is subject to the state's pricing rules and a $100 maximum product cost for qualifying non-sterile compounds.

Compounding fees vary based on whether the preparation is non-sterile or sterile, with applicable fees of $18.75 and $37.50. Non-sterile compounds are also subject to a one-prescription-per-30-day limitation.

Timelines

Pharmacy bills should generally be submitted within 1 year of the date of service. BWC or the applicable MCO generally has 30 days to process a properly documented bill. Providers may use the applicable MCO dispute resolution process for denied or reduced payments.

Pricing Source

Red Book / Medi-Span AWP Master Database and BWC Formulary Appendix.

State Fee Schedule

Oklahoma workers' compensation pharmacy reimbursement generally uses AWP × 0.90 + $5.00 for both brand-name and generic retail prescriptions.

Generic medications may also be subject to applicable Maximum Allowable Cost (MAC) pricing. Final reimbursement may be limited by the pharmacy's U&C price or a contracted network rate.

Direct Care

Yes. Oklahoma allows certified workplace medical plans to direct medical care and establish approved provider networks when applicable.

Pre-Authorization

Yes. Oklahoma uses a closed drug formulary. Certain excluded medications, compounds, and specialty drugs may require prior authorization.

OTC Restrictions

OTC medications generally require a valid prescription or clinical order from the authorized treating provider. The prescription should identify the appropriate strength and approximate quantity when applicable.

Approved OTC medications are subject to the standard pharmacy reimbursement methodology and may not include additional handling or compounding surcharges.

Topical Restrictions

Commercial topical medications are generally reimbursed under the standard AWP × 0.90 + $5.00 methodology.

Topical compounds may be subject to a $200 maximum reimbursement for a 30-day supply, prorated when appropriate. Certain OTC topical products may also have separate reimbursement limits.

Compound Restrictions

Compounds must be billed by individual ingredient with the applicable NDC and quantity information. Ingredients are generally priced at AWP × 0.90, with invalid or missing NDC information potentially resulting in non-reimbursement.

Compounds require the applicable prior authorization before processing.

Timelines

Pharmacy bills should generally be submitted within 1 year of the dispensing date. Carriers or administrators generally have 30 days to process a properly documented bill.

Providers disputing an unpaid or reduced bill may use the Oklahoma Workers' Compensation Commission's applicable payment dispute process.

Pricing Source

Red Book / Medi-Span AWP Master Database.

State Fee Schedule

Oregon workers' compensation pharmacy reimbursement uses AWP-based pricing for retail prescriptions. Brand-name medications are generally reimbursed at AWP × 0.85 + $2.00, while generic medications are generally reimbursed at AWP × 0.80 + $2.00.

Generic medications may also be subject to applicable MAC pricing. Final reimbursement may be limited by the pharmacy's U&C price or a contracted network rate.

Direct Care

No. Oregon generally allows an injured worker to select their initial treating provider. Additional provider or network requirements may apply when an employer participates in a certified managed care organization.

Pre-Authorization

No. Oregon generally operates with an open formulary structure, although generic substitution and utilization controls may apply to certain medications.

OTC Restrictions

OTC medications generally require a valid prescription or clinical order connected to the accepted workplace injury. Approved OTC medications are subject to retail-based reimbursement rules and may be limited by the pharmacy's actual retail or U&C price.

Topical Restrictions

Commercial topical medications are generally reimbursed at the applicable AWP-based rate. Certain high-cost or specialty topical products may require additional utilization review or documentation of medical necessity.

Compound Restrictions

Compounded medications must be billed by individual ingredient with the applicable NDC and quantity information.

Brand ingredients are generally subject to AWP × 0.85 pricing, while generic ingredients are subject to AWP × 0.80 pricing. A single $10.00 compounding fee applies rather than separate stacked fees.

Prior authorization may be required for compounded medications.

Timelines

Pharmacy bills should generally be submitted within 1 year of the dispensing date. Payers generally have 45 days to process a properly documented bill.

Providers disputing a denial may use the Oregon Workers' Compensation Division's administrative review process within the applicable timeframe.

Pricing Source

Red Book / Medi-Span AWP Master Database.

State Fee Schedule

Federal OWCP pharmacy reimbursement uses AWP-based pricing. Brand-name prescriptions are generally calculated at AWP × 0.85 + $4.00, while generic medications and applicable non-drug items are calculated at AWP × 0.60 + $4.00.

Final reimbursement may be limited by the pharmacy's U&C price or an applicable contracted rate.

Direct Care

Yes. OWCP administers federal workers' compensation programs and establishes the applicable medical and pharmacy coverage requirements.

Pre-Authorization

Yes. OWCP applies centralized pharmacy utilization controls. Certain high-risk medications, compounds, and specialty treatments may require prior authorization.

OTC Restrictions

OTC medications generally require a valid prescription or clinical order from the authorized treating provider. Approved OTC items are subject to the applicable federal reimbursement methodology and must be processed through the required electronic pharmacy system.

Topical Restrictions

Commercial topical medications are generally reimbursed under the applicable brand or generic AWP methodology. Certain topical medications may be subject to quantity limits or other utilization controls.

Repackaged products may also require verification against the original manufacturer's NDC and pricing information.

Compound Restrictions

Compounds must be billed by individual ingredient with the applicable NDC and quantity information. Compound ingredients are generally subject to AWP × 0.30 + $4.00 reimbursement.

A single $4.00 dispensing fee applies, with additional compounding or handling fees generally not permitted. Compounds may require prior authorization.

Timelines

Retail pharmacies should submit eligible claims through the required OWCP electronic pharmacy process at the time of dispensing. Enrolled providers must also maintain the required EFT information for electronic payment.

Providers disputing a fee reduction may use the applicable OWCP fee reconsideration process, generally within 30 days of the payment or remittance.

Pricing Source

Red Book Master AWP Database.

State Fee Schedule

Pennsylvania workers' compensation pharmacy reimbursement generally uses AWP × 1.10 for brand-name and generic retail prescriptions.

If AWP is unavailable for a specific drug, an alternative WAC-based methodology may apply. Final reimbursement may also be limited by the pharmacy's U&C price or a contracted network rate.

Direct Care

Yes. When statutory requirements are met, an employer may establish a designated provider panel and direct medical care during the applicable initial treatment period.

Pre-Authorization

Yes. Pennsylvania uses the applicable drug formulary framework. Medications requiring authorization must receive approval before reimbursement.

OTC Restrictions

OTC medications generally require a valid prescription or clinical order connected to the accepted workplace injury. Approved OTC prescriptions must be processed through the appropriate electronic pharmacy system and are subject to the applicable AWP and U&C pricing rules.

Topical Restrictions

Commercial topical medications are generally subject to the lower of the applicable AWP × 1.10 rate or Federal Upper Limit pricing when applicable.

Non-prescription topical products may have separate 30-day reimbursement limits, including $31.21 for standard topicals and $72.83 for topical patches. Topical compounds may be subject to a $200 30-day product limit.

Compound Restrictions

Compounds must be billed by individual ingredient with the applicable NDC and quantity information. Valid ingredients are generally reimbursed at AWP × 1.10.

An authorized compound may qualify for a single $20.00 compounding fee, with total product reimbursement capped at $400 per 30-day supply.

Compounds that duplicate commercially available FDA-approved products are not reimbursable.

Timelines

Pharmacy bills should generally be submitted within 1 year of the dispensing date. Payers generally have 30 days to process properly documented bills.

Providers disputing a payment may file the applicable Form LIBC-507 Application for Fee Review, subject to the applicable filing deadline.

Pricing Source

Red Book / Medi-Span AWP Master Database.

State Fee Schedule

Puerto Rico operates through a centralized workers' compensation system administered by the Corporación del Fondo del Seguro del Estado (CFSE). Standard open retail pharmacy billing is generally not available under the centralized system.

Covered medications are distributed through authorized CFSE pharmacy facilities rather than through a standard independent retail pharmacy fee schedule.

Direct Care

Yes. Puerto Rico operates through a centralized workers' compensation system. Medical care and pharmacy services are administered through CFSE facilities and established treatment pathways.

Pre-Authorization

Yes. CFSE uses a centralized formulary and authorization process. Certain brand-name medications, specialty drugs, and compounds may require prior authorization.

OTC Restrictions

OTC medications generally require a clinical order from an authorized CFSE physician. Approved OTC medications are distributed through the applicable CFSE pharmacy system.

Commercial retail purchases are generally not reimbursed through manual receipts.

Topical Restrictions

Commercial topical medications must meet CFSE formulary requirements before they can be dispensed. Approved products are distributed through authorized CFSE facilities and may be subject to quantity and diagnostic restrictions.

Compound Restrictions

Compounded medications are heavily restricted within the centralized system. When medically necessary, qualifying compounds may be prepared through the CFSE Industrial Hospital pharmacy.

External compounding fees and handling charges do not apply.

Timelines

Traditional retail pharmacy billing and prompt-pay timelines generally do not apply because pharmacy services are administered within the centralized CFSE system.

An injured worker disputing a medical necessity or formulary decision may use the applicable CFSE and Puerto Rico Industrial Commission appeal process.

Pricing Source

CFSE Centralized Institutional Purchasing Inventory Ledger.

State Fee Schedule

Rhode Island workers' compensation pharmacy reimbursement generally uses AWP × 0.90 for brand-name and generic retail prescriptions.

In certain pricing disputes, actual acquisition cost may be considered. Final reimbursement is generally subject to the applicable fee schedule, U&C pricing, and other payment limitations.

Direct Care

No. Rhode Island generally follows an employee-choice model for selecting a treating provider and pharmacy, subject to applicable workers' compensation requirements.

Pre-Authorization

No. Rhode Island generally operates with an open formulary structure, although utilization controls and medication-specific requirements may apply.

OTC Restrictions

OTC medications generally require a valid prescription or clinical order related to the accepted workplace injury. Approved OTC prescriptions must be submitted electronically through the applicable pharmacy billing process and are subject to AWP and U&C pricing limitations.

Topical Restrictions

Commercial topical medications are generally reimbursed at AWP × 0.90. Pharmacy claims should include the applicable NDC and quantity information.

Repackaged topical products may be evaluated using the original manufacturer's NDC and pricing information.

Compound Restrictions

Compounds must be billed by individual ingredient with the applicable NDC, quantity, and charge information. Ingredients are generally reimbursed at AWP × 0.90.

Topical compound ingredients must be FDA-approved for topical use. Reimbursement for topical compounds is generally capped at $500 per prescription for a 30-day supply, subject to the applicable U&C and fee schedule limits.

Timelines

Pharmacy bills should generally be submitted within 1 year of the dispensing date. Payers generally have 21 days to process a properly documented bill.

Providers disputing a payment may use the applicable Rhode Island medical review process, subject to the applicable filing deadline.

Pricing Source

Red Book / Medi-Span AWP Master Database.

State Fee Schedule

South Carolina uses an AWP-based reimbursement methodology for retail pharmacy prescriptions. Brand-name and generic medications are generally reimbursed at the lesser of:

• 100% of the published AWP plus a $5.00 dispensing fee

• The pharmacy's usual and customary (U&C) charge

• A lower contracted network rate

If an active AWP is unavailable, reimbursement may instead be based on 100% of the Wholesale Acquisition Cost (WAC) plus the $5.00 dispensing fee.

Sources: South Carolina Workers' Compensation Commission Medical Services Provider Manual, Section 10; Optum Pharmacy Resource Guide, March 2026.

Direct Care

Yes. South Carolina follows an employer-choice framework for medical care. The employer or insurance carrier generally has the authority to select and designate the treating physician and related pharmacy services.

Sources: South Carolina Code of Laws Title 42, Section 42-15-60; South Carolina Workers' Compensation Commission Insurance and Medical Services Guidelines.

Pre-Authorization

No. South Carolina generally operates under an open formulary framework, with pharmacy networks applying applicable generic substitution and utilization requirements.

Source: S.C. Code Ann. § 42-15-60; South Carolina Workers' Compensation Commission.

OTC Restrictions

OTC medications are generally not reimbursable unless they are supported by a valid prescription or clinical order from the authorized treating physician and are related to the accepted workplace injury.

When prescribed, OTC medications must be billed through the appropriate electronic pharmacy transaction process. Reimbursement is generally limited to the lesser of the applicable AWP-based amount plus the $5.00 dispensing fee or the pharmacy's U&C charge.

Sources: South Carolina Workers' Compensation Commission Medical Services Provider Manual, Section 1 and Pharmacy Guidelines.

Topical Restrictions

Non-compounded prescription creams, ointments, gels, patches, and similar topical medications are generally reimbursed under South Carolina's standard retail pharmacy pricing methodology, subject to the applicable AWP plus $5.00 formula.

Topical medications may also be subject to NDC verification and quantity or utilization limits.

Sources: South Carolina Workers' Compensation Commission Medical Services Provider Manual Pharmacy Guidelines; Enlyte South Carolina Fee Schedule Resource Portal.

Compound Restrictions

Compounded medications must identify the individual ingredients and applicable NDC information when submitted for reimbursement.

Eligible ingredients are generally priced using the applicable AWP, while ingredients with missing or invalid NDC information may not be reimbursable. A single $5.00 dispensing fee applies to the compound rather than separate fees for each ingredient.

Compounds may also require prior authorization before dispensing.

Sources: South Carolina Workers' Compensation Commission MSPM; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Billing deadline: Pharmacy bills must generally be submitted within 1 year (365 days) of dispensing.

• Payment: Payers generally have 30 days to process a properly submitted bill.

• Employee billing: Injured workers should not be balance-billed for covered workers' compensation pharmacy services.

• Disputes: Providers may challenge payment or reimbursement decisions through the applicable Workers' Compensation Commission hearing process, including Form 58 when required.

Sources: South Carolina Code of Laws Title 42; South Carolina Workers' Compensation Commission Regulations, Chapter 67, Article 13.

Pricing Source

Red Book Master AWP Database

Sources: South Carolina Code of Laws Title 42; South Carolina Workers' Compensation Commission.

State Fee Schedule

South Dakota does not apply a standard AWP percentage formula to retail pharmacy prescriptions. Brand-name and generic medications are generally reimbursed at the lesser of:

• The pharmacy's usual and customary (U&C) charge

• An applicable contracted network rate

The U&C charge should reflect the pharmacy's prevailing community price.

Sources: ARSD 47:03:05:01; ARSD 47:03:05:14; South Dakota Department of Labor and Regulation Workers' Compensation Division.

Direct Care

Yes. South Dakota provides employees with the right to make the initial selection of their treating medical practitioner under SDCL 62-4-43, subject to applicable workers' compensation requirements.

Sources: SDCL 62-4-43; South Dakota Department of Labor and Regulation.

Pre-Authorization

No. South Dakota generally follows an open formulary framework, although insurers may apply utilization management requirements to certain medications.

Source: S.D. Codified Laws § 62-4-1; South Dakota Department of Labor and Regulation.

OTC Restrictions

OTC medications are generally not reimbursable unless supported by a valid prescription or clinical order related to the accepted workplace injury.

Prescribed OTC medications should be submitted through the applicable electronic pharmacy billing process. Reimbursement is generally limited to the lesser of the pharmacy's U&C charge or an applicable contracted network rate.

Sources: ARSD 47:03:05:14; Optum Pharmacy Resource Guide, March 2026.

Topical Restrictions

Non-compounded topical prescription medications are generally reimbursed under South Dakota's standard retail pharmacy pricing rules, based on the pharmacy's U&C charge or applicable contracted rate.

Certain topical medications may be subject to quantity or utilization limits.

Sources: ARSD 47:03:05:14; Optum Pharmacy Resource Guide, March 2026.

Compound Restrictions

Compounded prescriptions should identify the individual ingredients and applicable NDC information.

Components are generally reimbursed based on the applicable community U&C value or contracted network rate. Compounded medications may also be subject to prior authorization requirements.

Sources: ARSD 47:03:05:14; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Billing deadline: Pharmacy bills must generally be submitted within 1 year (365 days) of dispensing.

• Payment: Payers must process properly submitted medical bills according to applicable state requirements.

• Employee billing: Providers generally cannot collect amounts above applicable workers' compensation reimbursement limits from the injured employee.

• Disputes: Providers must generally follow the insurer's internal dispute process before requesting a formal hearing. Applicable rules may provide a 30-day period for subsequent action.

Sources: ARSD 47:03:05:05; ARSD 47:03:05:06.

Pricing Source

Pharmacy Submitted Community Value Registers and PBM Contracted Rates.

State Fee Schedule

Tennessee uses an AWP-based reimbursement methodology for retail pharmacy prescriptions.

Brand-name and generic medications are generally reimbursed at the lesser of:

• AWP plus a $5.10 dispensing fee

• The pharmacy's usual charge

• A lower contracted amount

The original manufacturer's NDC should be used when determining AWP. If the original NDC is unavailable, applicable rules may require the AWP of the lowest-priced therapeutically equivalent drug.

Sources: Tenn. Comp. R. & Regs. 0800-02-18-.12; Tennessee Bureau of Workers' Compensation Medical Fee Schedule Handbook.

Direct Care

Yes. Tennessee follows an employer-choice framework. Employers must generally provide a written panel of at least three physicians from which the injured employee selects the treating physician.

Sources: T.C.A. § 50-6-204; Tenn. Comp. R. & Regs. 0800-02-18-.12; Tennessee Bureau of Workers' Compensation.

Pre-Authorization

Yes. Tennessee uses the ODG Drug Formulary. Certain medications require prospective prior authorization based on their formulary status.

Source: Tenn. Code Ann. § 50-6-204; Tennessee Bureau of Workers' Compensation.

OTC Restrictions

OTC medications are generally not reimbursable unless supported by a valid prescription or clinical order.

When prescribed, OTC medications are reimbursed based on the pharmacy's usual retail price. No separate filling fee is reimbursed for OTC medications.

Sources: Tenn. Comp. R. & Regs. 0800-02-18-.12; Tennessee Bureau of Workers' Compensation Medical Fee Schedule Handbook.

Topical Restrictions

Non-compounded topical prescriptions are generally reimbursed using the applicable AWP plus the $5.10 filling fee.

Prescription topical compounds are subject to a maximum reimbursement of $240 for a 30-day supply, with amounts prorated based on the days supplied when applicable.

Ingredients used in topical compounds must meet applicable FDA requirements for topical use.

Sources: Tenn. Comp. R. & Regs. 0800-02-18-.12; Tennessee Workers' Compensation Medical Fee Schedule Handbook.

Compound Restrictions

Compound prescriptions must identify the individual ingredients and use the original manufacturer's NDC information when applicable.

Ingredient reimbursement is based on the applicable manufacturer's AWP. Repackaged NDCs are not used as the original manufacturer's NDC for reimbursement purposes.

A single $5.10 filling fee applies to the compound.

Sources: Tenn. Comp. R. & Regs. 0800-02-18-.12; Tennessee Bureau of Workers' Compensation Medical Fee Schedule Handbook.

Timelines

• Billing deadline: Pharmacy bills must generally be submitted within 1 year (365 days) of dispensing.

• Payment: Payers generally have 30 days to pay an undisputed bill.

• Employee billing: Providers must bill the workers' compensation payer rather than balance-billing the injured employee for covered services.

• Disputes: Providers may use the Bureau's medical dispute process, including Form C-42 when applicable.

Sources: Tenn. Comp. R. & Regs. 0800-02-17-.13; Tennessee Bureau of Workers' Compensation Dispute Resolution Guidelines.

Pricing Source

Medi-Span Price Alert and IBM Micromedex Red Book Online.

State Fee Schedule

Texas uses separate AWP-based formulas for brand-name and generic retail prescriptions:

• Brand-name: AWP × 1.09 + $4.00 dispensing fee

• Generic: AWP × 1.25 + $4.00 dispensing fee

Reimbursement is generally limited to the lesser of the applicable fee schedule amount or the provider's billed amount.

If a drug cannot be priced using the standard methodology, reimbursement may be determined using the fair and reasonable standard established under Texas law.

Sources: 28 TAC § 134.503; Texas Labor Code § 408.028(f); Texas DWC Pharmacy Fee Guideline.

Direct Care

No. Texas uses a certified workers' compensation health care network framework. When an employer participates in a certified network, prescription services may be reimbursed under applicable network contracts.

Sources: Texas Insurance Code Chapter 1305; 28 TAC § 134.503; Texas Labor Code § 408.0281.

Pre-Authorization

Yes. Texas uses the ODG Appendix A Drug Formulary. Medications designated as requiring authorization and compound medications may require prospective prior authorization.

Source: Texas Labor Code § 408.028; Texas Division of Workers' Compensation.

OTC Restrictions

OTC medications are generally not reimbursable unless prescribed by the authorized treating doctor.

When prescribed, reimbursement is based on the retail price of the lowest reasonably available package quantity needed to fill the prescription.

No separate dispensing fee applies to OTC medications.

Sources: 28 TAC §§ 134.502(a), 134.503(d); Texas Department of Insurance Division of Workers' Compensation.

Topical Restrictions

Non-compounded topical medications are generally reimbursed under the applicable Texas brand or generic formula:

• Generic: AWP × 1.25 + $4.00

• Brand: AWP × 1.09 + $4.00

Certain topical medications may also be subject to quantity limits, including applicable supply restrictions.

Sources: 28 TAC §§ 134.502(c), 134.503(c); Texas DWC Pharmacy Fee Guideline.

Compound Restrictions

Compounded prescriptions must list each ingredient separately and identify the applicable drug information.

Each ingredient is priced using the applicable brand or generic reimbursement formula. Ingredients without valid NDC information may not be reimbursable.

A $15.00 compounding fee applies per prescription.

Compounds are treated as Status N medications under Texas's closed formulary and require prospective prior authorization.

Sources: 28 TAC §§ 134.502(d), 134.503(c); Texas Department of Insurance.

Timelines

• Billing deadline: Pharmacy bills must generally be submitted within 95 days of the date of service.

• Payment: Payers generally have 45 days to process a clean, undisputed bill.

• Employee billing: Texas law prohibits balance-billing an injured employee for covered workers' compensation services.

• Disputes: Providers may request Medical Fee Dispute Resolution using DWC Form-060, generally within 1 year of the date of service.

Sources: 28 TAC §§ 133.20, 133.307; Texas Labor Code § 413.042.

Pricing Source

Nationally Recognized Pharmaceutical Price Guides, including Red Book and Medi-Span AWP Databases.

State Fee Schedule

Utah does not use a standard AWP percentage formula for retail pharmacy prescriptions. Reimbursement is generally based on a fair and reasonable fee or the provider's standard charge, whichever is less.

The amount may also be compared with the price generally charged to the public and applicable contracted network rates.

Sources: Utah Code Ann. § 34A-2-407; Utah Admin. Code R612-300-1; Optum Pharmacy Resource Guide, March 2026.

Direct Care

Yes. Utah allows self-insured employers and insurance carriers to establish managed care or Preferred Provider Programs under applicable workers' compensation rules.

Sources: Utah Admin. Code R612-300-1 and R612-300-2; Utah Labor Commission

Pre-Authorization

Yes. Utah uses the ODG Drug Formulary. Certain nonpreferred or Status N medications may require prospective prior authorization.

Source: Utah Code § 34A-2-407; Utah Labor Commission Rules.

OTC Restrictions

OTC medications are generally not reimbursable unless supported by a valid prescription or clinical order related to the workplace injury.

Prescribed OTC medications must be billed through the applicable electronic pharmacy process and are generally reimbursed at the lesser of the pharmacy's U&C charge or an applicable contracted network rate.

Sources: Utah Code Ann. § 58-17b-102; Optum Pharmacy Resource Guide, March 2026.

Topical Restrictions

Non-compounded topical prescriptions are generally reimbursed under Utah's standard retail pharmacy pricing rules, based on the pharmacy's U&C charge or applicable contracted rate.

Certain topical medications may be subject to quantity and utilization limits.

Sources: Utah Labor Commission Medical Fee Standard; Optum Pharmacy Resource Guide, March 2026.

Compound Restrictions

Compounded prescriptions should identify the individual ingredients and applicable NDC information.

Ingredients are generally reimbursed based on their applicable community value or contracted network rate.

Compounds may be subject to prior authorization before dispensing.

Sources: Utah Code Ann. § 58-17b-611; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Billing deadline: Pharmacy bills must generally be submitted within 1 year (365 days) of dispensing.

• Payment: Payers generally have 45 days to process an undisputed bill.

• Employee billing: Injured workers should not be balance-billed for covered workers' compensation pharmacy services.

• Disputes: Providers may file an Application for Hearing with the Utah Labor Commission within the applicable deadline following an adverse determination.

Sources: Utah Admin. Code R612-300-7; Utah Code Ann. § 34A-2-407.

Pricing Source

Pharmacy Submitted Community Value Registers and PBM Contracted Rates.

State Fee Schedule

• Retail brand-name and generic prescriptions are reimbursed at the published AWP plus a $3.15 dispensing fee, subject to the lesser of the fee schedule amount or the pharmacy's billed charge.

• The billed charge must reflect the pharmacy's standard charge for the same medication and service.

• Source: Vermont Department of Labor Workers' Compensation Rules; Optum Pharmacy Resource Guide, March 2026.

Direct Care

• No. Injured workers generally have the right to select their initial treating provider or pharmacy under Vermont workers' compensation rules.

• Source: Vermont Statutes Annotated, Title 21, Section 640(a); Vermont Department of Labor.

Pre-Authorization

• No. Retail prescriptions generally follow the state's AWP-based fee schedule rather than a separate pharmacy pre-authorization requirement.

• Source: Vermont Statutes Annotated, Title 21, Section 640; Vermont Department of Labor.

OTC Restrictions

• OTC medications generally require a valid prescription or clinical order to qualify for reimbursement.

• Prescribed OTC medications must be billed through the applicable electronic pharmacy claims process and are subject to the state's standard reimbursement limits.

• Source: Vermont Department of Labor Workers' Compensation Rules; Optum Pharmacy Resource Guide, March 2026.

Topical Restrictions

• Standard topical prescriptions are reimbursed under the state's retail pharmacy pricing formula.

• Topical compounds may be subject to a $200 maximum for a 30-day supply, prorated when applicable.

• Quantity limits may apply to certain topical medications and patches.

• Source: Vermont Department of Labor Workers' Compensation Rules; Optum Pharmacy Resource Guide, March 2026.

Compound Restrictions

• Compounded prescriptions must identify individual ingredients and applicable NDCs when billed electronically.

• Ingredient reimbursement is based on the applicable AWP, with invalid or unrecognized NDCs potentially excluded from payment.

• Only one $3.15 dispensing fee applies to the compound transaction.

• Source: Vermont Department of Labor Workers' Compensation Rules; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Pharmacy claims must be submitted within the applicable Vermont billing period.

• Payers generally have 30 days to process a properly submitted bill under applicable state rules.

• Injured workers should not be balance-billed for covered workers' compensation treatment.

• Payment disputes may be appealed through the Vermont Department of Labor.

• Source: Vermont Statutes Annotated, Title 21, Section 640(a); Vermont Department of Labor Rule 40.010.

Pricing Source

• Red Book / Medi-Span AWP databases.

• Source: Vermont Rule 40.000; Vermont Department of Labor.

State Fee Schedule

• Retail pharmacy prescriptions are generally reimbursed based on the prevailing community rate rather than a standard state pharmacy fee schedule.

• Employer liability is limited to reasonable charges prevailing in the community for similar services or medications.

• Pharmacy charges may be reviewed or challenged when their reasonableness is disputed.

• Source: Code of Virginia, Section 65.2-605; Virginia Workers' Compensation Commission Rule 14.

Direct Care

• No. Employers generally provide a panel of physicians from which the injured worker selects a treating physician.

• Source: Va. Code § 65.2-603.

Pre-Authorization

• No. Retail pharmacy prescriptions generally follow the prevailing community rate, although network and formulary requirements may apply.

• Source: Va. Code § 65.2-603; Virginia Workers' Compensation Commission.

OTC Restrictions

• OTC medications generally require a valid prescription or clinical order for reimbursement.

• Reimbursement is generally based on the prevailing community rate or applicable network rate.

• OTC products generally do not receive a separate professional dispensing fee.

• Source: Code of Virginia, Section 65.2-605; Optum Pharmacy Resource Guide, March 2026.

Topical Restrictions

• Standard topical prescriptions are generally reimbursed at the applicable prevailing community rate.

• Quantity limits may apply to certain topical medications and patches.

• Source: Code of Virginia, Section 65.2-605; applicable Virginia cost-containment guidance.

Compound Restrictions

• Compounded prescriptions should identify individual ingredients and applicable NDCs when billed.

• Components are evaluated based on applicable community pricing.

• Network requirements or prior authorization may apply to compounded medications.

• Source: Code of Virginia, Section 65.2-605; Virginia Workers' Compensation Commission Rule 14; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Providers must comply with applicable Virginia claim and payment dispute deadlines.

• Injured workers generally should not be balance-billed for covered workers' compensation treatment.

• Payment disputes may be submitted to the Virginia Workers' Compensation Commission through the applicable review process.

• Source: Va. Code §§ 65.2-601 and 65.2-605; Virginia Workers' Compensation Commission.

Pricing Source

• Community pharmacy pricing and applicable Rule 14 regional guidelines.

• Source: Code of Virginia, Title 65; Virginia Workers' Compensation Commission.

State Fee Schedule

• Brand prescriptions are reimbursed at AWP × 0.90 plus a $4.50 dispensing fee.

• Generic prescriptions are reimbursed at AWP × 0.50 plus a $4.50 dispensing fee.

• Payment may be limited to the lower of the applicable fee schedule amount, the pharmacy's public charge, or an applicable network rate.

• Source: WAC 296-20-010; WAC 296-20-01002; Washington L&I MARFS, Chapter 19.

Direct Care

• No. Injured workers generally have the right to select an attending provider within the applicable L&I medical provider network.

• Source: RCW 51.04.030; WAC 296-20-015.

Pre-Authorization

• Yes. Washington uses a preferred drug list and may require authorization for nonpreferred medications.

• Source: Washington L&I pharmacy formulary guidance.

OTC Restrictions

• OTC products generally require a valid prescription to qualify for reimbursement.

• Prescribed oral OTC products follow the generic pricing formula.

• Other OTC products may be subject to separate reimbursement rules.

• Source: Washington L&I MARFS, Chapter 19; Washington L&I Pharmacy Billing Guide.

Topical Restrictions

• Standard topical prescriptions are reimbursed under the applicable brand or generic pharmacy formula.

• Quantity and supply limits may apply to certain topical medications and patches.

• Source: Washington L&I MARFS, Chapter 19.

Compound Restrictions

• Compounded prescriptions must identify individual ingredients and applicable NDCs.

• Ingredients are reimbursed under the applicable brand or generic pricing methodology.

• A $4.50 dispensing fee applies, with additional compounding labor subject to applicable limits.

• Prior authorization may be required for compounded medications.

• Source: Washington L&I MARFS, Chapter 19; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Pharmacy claims generally must be submitted within one year of dispensing.

• Self-insured employers generally have 60 days to process an undisputed bill.

• Providers may not balance-bill an injured worker for an accepted claim.

• Payment disputes may be appealed through L&I or the Board of Industrial Insurance Appeals.

• Source: RCW 51.04.030; RCW 51.32.190; WAC 296-20-125.

Pricing Source

• Washington L&I Pharmacy Fee Schedule and recognized AWP databases.

• Source: Washington L&I; RCW Title 51; WAC Title 296.

State Fee Schedule

• Retail pharmacy prescriptions generally do not follow a percentage-based state fee schedule.

• Reimbursement is generally limited to the pharmacy's usual and customary charge, subject to applicable network arrangements.

• Charges may be reviewed for reasonableness.

• Source: D.C. Department of Employment Services; Optum Pharmacy Resource Guide, March 2026.

Direct Care

• No. Injured workers generally have the right to select their treating provider under District workers' compensation rules.

• Source: D.C. Official Code § 32-1507; D.C. Department of Employment Services.

Pre-Authorization

• No. The District does not use a standard state pharmacy fee schedule or closed formulary for retail prescriptions.

• Source: D.C. Official Code § 32-1507; DOES.

OTC Restrictions

• OTC medications generally require a valid prescription or clinical order for reimbursement.

• Reimbursement is subject to the applicable usual and customary or network rate.

• Source: D.C. Department of Employment Services; Optum Pharmacy Resource Guide, March 2026.

Topical Restrictions

• Standard topical prescriptions are generally reimbursed based on the pharmacy's usual and customary or applicable network rate.

• Quantity limits may apply to certain medications and patches.

• Source: D.C. Municipal Regulations, Title 7; Optum Pharmacy Resource Guide, March 2026.

Compound Restrictions

• Compounded prescriptions should identify individual ingredients and applicable NDCs.

• Components are generally evaluated using applicable usual and customary or network pricing.

• Prior authorization may apply to compounded medications.

• Source: D.C. Department of Employment Services; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Pharmacy claims generally must be submitted within one year of dispensing.

• Payers generally have 30 days to process an undisputed bill.

• Injured workers should not be balance-billed for covered treatment.

• Payment disputes may be submitted through the applicable DOES review process.

• Source: D.C. Official Code § 32-1507; DOES administrative rules.

Pricing Source

• Pharmacy usual and customary pricing and applicable PBM network rates.

• Source: D.C. Official Code, Title 32; DOES.

State Fee Schedule

• Retail prescriptions are generally priced using NADAC, or WAC when NADAC is unavailable, plus a $10.49 dispensing fee.

• Payment may be subject to applicable billed-charge or network pricing limits.

• Physician-dispensed medications may be subject to different dispensing-fee rules.

• Source: W. Va. Code § 23-4-3; W. Va. C.S.R. 85-20-14.

Direct Care

• Yes. Employers and carriers may use an approved managed care plan, which can require treatment through participating providers and pharmacies.

• Source: W. Va. Code § 23-4-3; W. Va. C.S.R. 85-21-3.

Pre-Authorization

• No. Standard retail prescriptions follow the applicable NADAC/WAC pricing methodology.

• Source: W. Va. Code § 23-4-3; Insurance Commissioner rules.

OTC Restrictions

• OTC medications generally require a valid prescription to qualify for reimbursement.

• Prescribed OTC products are subject to applicable retail and network pricing rules.

• Source: W. Va. Code § 23-4-3; Optum Pharmacy Resource Guide, March 2026.

Topical Restrictions

• Standard topical prescriptions follow the applicable NADAC/WAC pricing methodology and dispensing fee.

• Certain topical preparations may be subject to supply and reimbursement limits.

• Manufactured prescription patches may have separate reimbursement limits.

• Source: W. Va. C.S.R. 85-20-14; West Virginia Insurance Commissioner guidance.

Compound Restrictions

• Compounded prescriptions must identify individual ingredients and applicable NDCs.

• Ingredients are generally priced using NADAC or WAC.

• One $10.49 dispensing fee applies to the compound transaction.

• Prior authorization and documentation may be required for higher-cost compounds.

• Source: W. Va. C.S.R. 85-20-14; West Virginia Board of Pharmacy guidance.

Timelines

• Pharmacy claims generally must be submitted within the applicable state billing period.

• Payers generally have 30 days to process an undisputed bill.

• Providers may not balance-bill an injured worker for an allowed claim.

• Payment disputes must follow the applicable reconsideration and dispute-resolution process.

• Source: W. Va. Code § 23-4-3; W. Va. C.S.R. Title 85.

Pricing Source

• CMS National Average Drug Acquisition Cost (NADAC) data.

• Source: West Virginia Code Chapter 23; W. Va. C.S.R. Title 85.

State Fee Schedule

• Retail brand-name and generic prescriptions are capped at AWP plus a $3.00 dispensing fee.

• Payment may be limited to the lower of the fee schedule amount, the pharmacy's usual and customary price, or an applicable network rate.

• Bills must separately identify the drug price and dispensing fee and include the applicable NDC.

• Source: Wis. Stat. § 102.425; Wisconsin Department of Workforce Development.

Direct Care

• Yes. Injured workers generally have the right to select their treating provider under Wisconsin workers' compensation rules.

• Source: Wis. Stat. § 102.42(2).

Pre-Authorization

• No. Retail prescriptions generally follow the statutory AWP-based fee schedule.

• Source: Wis. Stat. § 102.425; Wisconsin DWD.

OTC Restrictions

• OTC medications generally require a valid prescription or clinical order for reimbursement.

• Nonprescription products are generally limited to the usual and customary charge to the public.

• A separate dispensing fee generally does not apply to OTC products.

• Source: Wis. Stat. § 102.425(5).

Topical Restrictions

• Standard topical prescriptions are reimbursed under the applicable AWP-based formula and dispensing fee.

• Quantity limits may apply to certain topical medications and patches.

• Source: Wis. Stat. § 102.425; Wisconsin DWD.

Compound Restrictions

• Compounded prescriptions should identify individual ingredients and applicable NDCs.

• Ingredients are generally priced using the applicable AWP.

• One $3.00 dispensing fee applies to the compound transaction.

• Source: Wis. Stat. § 102.425; Wisconsin DWD.

Timelines

• Payers disputing a prescription drug charge generally must provide written notice within 30 days of receiving a completed bill.

• Pharmacists may not collect a disputed covered charge from the injured worker.

• Injured employees may be entitled to reimbursement for qualifying out-of-pocket prescription expenses.

• Payment disputes may be submitted to the Wisconsin DWD Workers' Compensation Division.

• Source: Wis. Stat. §§ 102.425(3)(a), 102.425(4m)(b), 102.425(4m)(c).

Pricing Source

• Red Book / Medi-Span AWP databases.

• Source: Wis. Stat. § 102.425; Wisconsin DWD.

State Fee Schedule

• Brand-name and generic retail prescriptions are generally reimbursed at AWP × 0.90 plus a $5.00 dispensing fee.

• Payment may be limited to the lower of the fee schedule amount or the pharmacy's usual and customary charge.

• The submitted charge should reflect the pharmacy's standard public price.

• Source: Wyoming DWS Workers' Compensation Rules; Wyoming Administrative Code; Optum Pharmacy Resource Guide, March 2026.

Direct Care

• No. Wyoming operates through a state-administered workers' compensation system, with injured workers generally retaining the right to select their initial treating provider.

• Source: Wyo. Stat. § 27-14-401; Wyoming DWS.

Pre-Authorization

• No. Standard retail prescriptions follow the applicable AWP-based fee schedule, although prospective review may apply to certain medications.

• Source: Wyo. Stat. § 27-14-401; Wyoming DWS Chapter 9 rules.

OTC Restrictions

• OTC medications generally require a valid prescription from the treating provider to qualify for reimbursement.

• Prescribed OTC products are generally subject to the pharmacy's usual and customary or applicable network pricing.

• A separate dispensing fee generally does not apply to OTC products.

• Source: Wyoming Administrative Code; Optum Pharmacy Resource Guide, March 2026.

Topical Restrictions

• Standard topical prescriptions follow the applicable AWP-based pricing formula and $5.00 dispensing fee.

• Certain topical compounds may be subject to a $200 maximum for a 30-day supply, prorated when applicable.

• Quantity limits may apply to topical medications and patches.

• Source: Wyoming Administrative Code; Wyoming DWS Workers' Compensation Rules.

Compound Restrictions

• Compounded prescriptions must identify individual ingredients and applicable NDCs.

• Components are generally priced using the applicable AWP methodology.

• One $5.00 dispensing fee applies to the compound transaction.

• Prior authorization may be required for compounded medications.

• Source: Wyoming Administrative Code; Optum Pharmacy Resource Guide, March 2026.

Timelines

• Pharmacy claims generally must be submitted within one year of dispensing.

• Injured workers should not be balance-billed for covered workers' compensation treatment.

• Payment disputes must follow the applicable Wyoming DWS review process and deadlines.

• Source: Wyo. Stat. § 27-14-401; Wyoming DWS rules and fee schedules.

Pricing Source

• Red Book / Medi-Span AWP databases.

• Source: Wyoming Administrative Code; Wyoming DWS.