State-Specific Guidance for Dispensing

State Fee Schedule

• Brand-Name Formula: AWP + $5.00 professional dispensing fee.
• Generic Formula: AWP + $10.00 professional dispensing fee.
• Lesser-Of Rule: Final reimbursement is limited to the lowest of the applicable fee schedule amount, the pharmacy's usual and customary charge, or a contracted network rate.
• Alternative Pricing: If AWP is unavailable, the pricing benchmark changes to WAC × 1.20.

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

Direct Care

• No. Alaska allows injured workers to initially select a licensed attending physician under AS 23.30.095(a).

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

Pre-Authorization

• No. Alaska does not use a state-mandated closed drug formulary. Pharmacy transactions generally process without prior authorization unless PBM utilization controls apply, including controls for certain narcotics or compounds.

Source: Alaska Stat. 23.30.095

OTC Restrictions

• Prescription Requirement: OTC products are not reimbursable unless accompanied by a valid prescription from the authorized treating provider.
• Pricing: Validly prescribed OTC medications are reimbursed based on the lowest applicable generic NDC value.
• Dispensing Fee: OTC medications do not qualify for a professional dispensing or handling fee.

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

Topical Restrictions

• Standard Topicals: Commercially manufactured topical medications are priced under the standard retail formulas of AWP + $5.00 for brand or AWP + $10.00 for generic.
• Topical Compounds: Reimbursement is limited to the lesser of $200 for a 30-day supply, prorated as necessary, or the applicable compound fee schedule amount.
• Quantity Limits: High-cost topical medications may be subject to automated quantity and monthly utilization limits.

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

Compound Restrictions

• Ingredient Itemization: Compounds must be billed by individual ingredient through electronic NCPDP transactions, including weight and NDC information.
• Ingredient Pricing: Each ingredient is priced using the manufacturer's published AWP. Ingredients without valid NDCs are not reimbursable.
• Compounding Fee: A single $10.00 compounding fee may be added to the verified ingredient cost.

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

Timelines

• Payment: Medical bills must generally be paid within 30 days after receipt by the employer or insurer.
• Written Notice: If payment is disputed or denied, the employer must provide written notice explaining the reason within 30 days.
• Employee Protection: Injured workers cannot be balance-billed during an active billing or medical-necessity dispute.
• Disputes: Pharmacy providers may request a formal board determination hearing under AS 23.30.110 and 8 AAC 45.070.

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

Pricing Source

• Nationally Recognized Database Registers: Red Book / Medi-Span AWP Databases

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

State Fee Schedule

• Brand-Name Formula: AWP × 0.85 + $7 dispensing fee.
• Generic Formula: AWP × 0.75 + $7 dispensing fee.
• Generic Sourcing: Pharmacies and healthcare providers should dispense the lowest-AWP generic when available.
• Dispensing Fee: $7 per prescription.

Source: Industrial Commission of Arizona (ICA) Physicians' and Pharmaceutical Fee Schedule Guidelines, effective May 1, 2026 through April 30, 2027.

Direct Care

• No. Injured workers generally may choose their own physician, although the employer or carrier may select the physician for the initial visit. Self-insured employers authorized to direct care may select the treating physician for the duration of treatment.
• Injured workers may choose their pharmacy.

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

Pre-Authorization

• No. Medications included under the ODG formulary generally do not require pre-authorization. Providers may still request pre-authorization to obtain advance payer approval and reduce the risk of a medical-necessity denial.

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

OTC Restrictions

• OTC medications are reimbursed at the retail price when commercially available.
• Topical creams and lotions are limited to $30 for a 30-day supply, prorated as necessary.
• Topical patches are limited to $75 for a 30-day supply, prorated as necessary.

Topical Restrictions

• Non-Compound Topicals: Commercially manufactured topical medications are priced under the standard formulas of AWP × 0.85 for brand and AWP × 0.75 for generic.
• Topical Compounds: Maximum reimbursement is $240 for a 30-day supply, prorated as necessary.

Compound Restrictions

• Ingredient Itemization: Compounds must be billed by individual ingredient through electronic NCPDP transactions, including metric weight and NDC.
• Ingredient Pricing: Compound ingredients are priced using AWP × 0.85 for brand and AWP × 0.75 for generic.
• Dispensing Fee: Only one professional dispensing fee may be applied to the entire compound transaction.

Source: ICA 2026 Pharmaceutical Fee Schedule Ground Rules

Timelines

• Billing Submission: Pharmacies must submit properly coded electronic bills within applicable regional billing timelines.
• Employee Protection: Injured workers cannot be balance-billed during active billing or medical-necessity disputes.
• Payment Disputes: Pharmacies challenging an adverse payment decision must submit a formal written appeal. If the payer does not provide evidence of contract validity within 30 days, full fee schedule rates apply.

Sources: Arizona Revised Statutes (A.R.S.) 23-1062.01, ICA Medical Resource Office Dispute Guidelines

Pricing Source

• Medi-Span Price Alert Database Register

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

State Fee Schedule

• Brand-Name Formula: AWP + $5.13 professional dispensing fee.
• Generic Formula: AWP + $5.13 professional dispensing fee.
• Lesser-Of Rule: Reimbursement is limited to the lowest of the fee schedule amount, the pharmacy's submitted usual and customary charge, or an applicable contracted MCO/PPO rate.
• Arkansas applies the same $5.13 dispensing fee to brand-name 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

• Yes. Arkansas follows an employer-choice framework. The employer or carrier may select the initial treating physician or designate an authorized medical facility.

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

Pre-Authorization

• Yes. Arkansas uses a closed workers' compensation drug formulary incorporating the Public Employee Claims Division registry. Excluded medications and certain high-risk opioid therapies require advance adjuster approval.

Source: AWCC Rule 099.41 (Workers' Compensation Drug Formulary)

OTC Restrictions

• Prescription Requirement: OTC products are not reimbursable unless supported by a valid, signed prescription from the authorized treating provider.
• Pricing: Validly prescribed OTC products are reimbursed at the pharmacy's submitted usual and customary storefront cash price or applicable contracted rate.

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

Topical Restrictions

• Standard Topicals: Commercially manufactured topical medications are capped at the standard AWP + $5.13 formula.
• Quantity Limits: High-cost topical medications may be subject to automated quantity and utilization limits.

Source: AWCC Rule 099.41 Formularies

Compound Restrictions

• Ingredient Itemization: Compounds must be billed separately by active ingredient through electronic NCPDP transactions, including metric weight and NDC.
• Ingredient Pricing: Each component is priced up to the state's standard AWP + $5.13 formula.
• Dispensing Fee: Only one $5.13 professional dispensing fee applies to the entire compound transaction.

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

Timelines

• Billing Submission: Pharmacies must submit properly coded electronic bills within applicable billing timelines.
• Payment: Carriers, self-insured employers, and third-party administrators must process properly documented bills within applicable prompt-pay requirements.
• Employee Protection: Injured workers cannot be balance-billed for covered prescriptions during an active billing dispute.
• Disputes: Pharmacies may submit payment disputes through the AWCC Medical Cost Containment Division for administrative determination.

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

Pricing Source

• Nationally Recognized Database Registers: Red Book / Medi-Span AWP Databases

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

State Fee Schedule

• Brand-Name Formula: DWC weekly data file ingredient rate plus a professional dispensing fee of $10.05 or $13.20, depending on the pharmacy's attested tier.
• Generic Formula: DWC weekly data file ingredient rate plus a professional dispensing fee of $10.05 or $13.20, depending on the pharmacy's attested tier.
• Lowest-Cost Rule: When a drug is absent from the standard Medi-Cal pricing files, reimbursement defaults to the lowest applicable value among NADAC, WAC with 0% markup, FUL, or MAIC.
• AWP Exclusion: AWP is not used to determine outpatient drug ingredient reimbursement.

Sources: California Labor Code Section 5307.1, California Code of Regulations (CCR) Title 8, Section 9789.40, DWC Pharmaceutical Fee Schedule Official Directives

Direct Care

• Yes. California follows a hybrid employer-choice framework. Under Cal. Labor Code 4600, the employer may direct treatment and select the treating provider during the first 30 days after the injury is reported.

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

Pre-Authorization

• Yes. California uses the Medical Treatment Utilization Schedule (MTUS) Drug List, which separates medications into exempt and non-exempt categories. The April 30, 2026 updates added additional exempt migraine medications.

Source: Cal. Labor Code 5307.27 / DWC MTUS Formulary

OTC Restrictions

• Prescription Requirement: OTC products are not reimbursable unless accompanied by a valid, signed prescription from the authorized treating provider.
• Pricing: Validly prescribed OTC medications are capped at the pharmacy's submitted usual and customary storefront cash price or an applicable contracted network rate.

Sources: California Labor Code Section 5307.1, CCR Title 8, Section 9789.40, myMatrixx California Pricing Brief

Topical Restrictions

• Standard Topicals: Commercially manufactured topical medications are priced using the state's weekly DWC lowest-cost feed file.
• Quantity Limits: High-cost topical medications are subject to automated quantity and utilization controls and may be reduced or rejected when they exceed applicable limits.

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

Compound Restrictions

• Ingredient Itemization: Compounds must be billed separately by ingredient through electronic NCPDP transactions, including weight and NDC information.
• Ingredient Pricing: Each component is priced using the manufacturer's published data for the applicable NDC. Ingredients without valid NDCs are not reimbursable.
• Dispensing Fee: Only one professional dispensing fee may be applied to the complete compound transaction.

Sources: California Code of Regulations (CCR) Title 8, Section 9789.40.3, Optum Workers' Compensation Pharmacy Guide

Timelines

• Payment: Carriers, self-insured employers, and third-party administrators must pay or formally deny an electronically submitted pharmacy bill within 45 days of receipt.
• Employee Protection: Injured workers cannot be balance-billed during an active billing or medical-necessity dispute.
• Second Bill Review: A pharmacy disputing a payment decision must request a Second Bill Review (SBR) within 90 days of receiving the explanation of review.
• Independent Bill Review: If the dispute remains unresolved after SBR, the provider must file for Independent Bill Review (IBR) within 30 days.

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

Pricing Source

• California DWC Official Weekly Pharmaceutical Fee Data File and National Provider Identifier (NPI) File

Sources: California Labor Code Title 8, Division of Workers' Compensation Official Year Directories

State Fee Schedule

• Brand and Generic Reimbursement: Both brand-name and generic medications are reimbursed using the same formula: AWP + $4.00.
• AWP Alternative: When a drug does not have a published AWP, reimbursement is calculated using WAC × 1.20.
• Retail Pharmacy Requirement: Licensed retail pharmacies are the exclusive dispensing channel for certain workers' compensation medications, including opioids, scheduled controlled substances, benzodiazepines, and gabapentin.
• Repackaged Drugs: For repackaged or relabeled medications, reimbursement is based on the original manufacturer's stock package NDC and its applicable AWP.

Sources: Colorado Department of Labor and Employment (CDLE), Division of Workers' Compensation Rules of Procedure, Rules 18-6(1) and 18-6(2); Optum Workers' Compensation Pharmacy Resource Guide

Direct Care

• No: Injured workers generally may fill authorized workers' compensation prescriptions at any licensed retail pharmacy of their choice, provided the pharmacy accepts Colorado workers' compensation fee schedule rates.

Sources: CDLE Division of Workers' Compensation Rules of Procedure, Rules 16 and 18-6; C.R.S. 8-43-404

Pre-Authorization

• Yes: Colorado uses the Medical Treatment Guidelines (MTG) Formulary. Certain treatments, including high-dose narcotic regimens, compounds, and patch kits, may require prior authorization.

Source: 7 CCR 1101-3 Rule 17 (Medical Treatment Guidelines)

OTC Restrictions

• Prescription Requirement: OTC products are not reimbursable unless supported by a valid, signed prescription from the Authorized Treating Provider (ATP) documenting medical necessity.
• Reimbursement Formula: Prescribed OTC medications are reimbursed using the standard drug pricing formula of AWP + $4.00, or WAC × 1.20 when AWP is unavailable.
• Dispensing Fee: Licensed retail pharmacies may receive the full $4.00 professional dispensing fee for properly prescribed OTC medications.

Sources: CDLE Division of Workers' Compensation Rules of Procedure, Rules 18-6(1) and 18-6(2); Optum Pharmacy Resource Guide, 2026 updates

Topical Restrictions

• Prior Authorization: Brand-name or prescription-strength topical medications may require written prior authorization when a therapeutically equivalent alternative is available for at least $100 less for the same supply period.
• OTC Topical Caps: Prescribed OTC creams, gels, and ointments are capped at $31.21 per 30-day supply, while non-prescription patches are capped at $72.83 per 30-day supply. Amounts are prorated when applicable.
• Repackaged Topicals: Repackaged or relabeled topical products are priced using the original manufacturer's stock package NDC and AWP rather than the repackager's pricing.

Sources: CDLE Division of Workers' Compensation Rules of Procedure, Rules 18-6(1) and 18-6(4); Optum Workers' Compensation Pharmacy Resource Guide, 2026/2027 updates

Compound Restrictions

• Ingredient-Level Billing: Each ingredient in a compounded medication must be billed separately with its quantity and valid 11-digit NDC. Ingredients without a valid NDC are reimbursed at $0.00.
• Z-Code Limits: Topical compounds are subject to four state pricing tiers for a 30-day supply, prorated when necessary:
  • Category I (Z0790): $81.90 maximum
  • Category II (Z0791): $163.20 maximum
  • Category III (Z0792): $270.30 maximum
  • Category IV (Z0793): $377.40 maximum
• Non-Topical Compound Cap: Compounds outside the Z-code limits are capped at the lesser of $200.00 per 30-day supply or the amount calculated under the standard fee schedule.
• Compounding Fee: Contracted retail pharmacies may receive one $10.00 compounding fee per prescription.

Sources: CDLE Division of Workers' Compensation Rules of Procedure, Rule 18-6; Optum Workers' Compensation Pharmacy Resource Guide, 2026/2027 updates

Timelines

• Submission Deadline: Workers' compensation bills must be submitted within 120 days of the date of service.
• Electronic Billing: Providers submitting 25 or more workers' compensation bills per month must use electronic billing through standard HIPAA X12 837 formats.
• Receipt Confirmation: Payers and PBM networks must acknowledge receipt of an electronic bill within 2 business days.
• Payment or Denial: Clean bills must be paid, reduced, or denied within 30 calendar days of receipt.
• Late Payment Interest: Uncontested balances paid late are subject to 1% monthly interest.
• Disputes: Reconsideration must be submitted to the payer within 60 days of the original Explanation of Review (EOR). If denied, a formal fee dispute may be submitted to the Division of Workers' Compensation within 90 days of the reconsideration EOR.

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

Pricing Source

• Pricing Databases: Medi-Span or Red Book.

Sources: CDLE Division of Workers' Compensation Rules of Procedure, Rules 16 and 18-6; Colorado Medical Fee Schedule updates

State Fee Schedule

• Updated Reimbursement Structure: Effective July 15, 2026, Connecticut replaced its previous AWP-plus model with a discounted AWP structure under Commission Memorandum No. 2026-04.
• Brand Medications: Reimbursed at AWP × 20%, plus a $5.00 dispensing fee.
• Generic Medications: Reimbursed at AWP × 80%, plus an $8.00 dispensing fee.
• Missing or Unavailable NDC: When the original manufacturer NDC is missing or cannot be verified, the payer's billing network may use an appropriate therapeutically equivalent source NDC and its associated AWP to determine reimbursement.

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

Direct Care

• Yes: When an employer uses a state-certified Managed Care Plan (MCP), the employer directs medical care through the plan's network. Injured workers must generally select an attending physician from the designated network.
• When no approved MCP is in place, the employer may still direct the initial medical visit to a designated clinic, walk-in facility, or hospital emergency room.

Sources: Connecticut General Statutes §§ 31-279-10 and 31-294d; Connecticut Workers' Compensation Commission Administrative Regulations

Pre-Authorization

• Yes: Connecticut uses a fee schedule and utilization review structure that distinguishes between brand and generic medications. Non-preferred medications may require prospective pre-certification.

Source: Conn. Gen. Stat. § 31-294d; Connecticut Workers' Compensation Commission Guidelines

OTC Restrictions

• Prescription Requirement: OTC products are not reimbursable under workers' compensation unless supported by a valid, signed prescription from the Authorized Treating Provider (ATP) confirming medical necessity.
• Brand OTC Formula: AWP + $5.00.
• Generic OTC Formula: AWP + $8.00.
• Dispensing Fee: Pharmacies may receive the applicable $5.00 brand or $8.00 generic dispensing fee for prescribed OTC medications.

Sources: Connecticut Workers' Compensation Commission Practitioner Fee Schedule Guidelines, Section III(C); Optum Workers' Compensation Pharmacy Resource Guide, 2026 updates

Topical Restrictions

• No Specific State Caps: Connecticut does not establish formal reimbursement caps, category limits, or volume restrictions specifically for commercially manufactured standalone topical medications.
• Standard Pricing: Topical medications are generally processed using applicable PBM contract rates and the standard brand or generic fee schedule formulas.
• Prior Authorization: Premium or brand-name topical products that fall outside standard utilization parameters may require prior authorization.

Sources: Connecticut Workers' Compensation Commission Administrative Rules; Optum Workers' Compensation Pharmacy Resource Guide

Compound Restrictions

• No Specific State Compound Cap: Connecticut does not publish a dedicated fee-schedule cap for custom-compounded medications dispensed through retail pharmacies.
• Ingredient-Based Pricing: PBM networks generally process compounds by individual ingredient using the applicable NDC and AWP.
• Prior Authorization: Compounded medications are treated as non-formulary preparations and may require written prior authorization before payment is approved.

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

Timelines

• Electronic Claims: Standard pharmacy claims may be processed electronically through real-time pharmacy networks.
• Back-Billed Claims: Paper or back-billed pharmacy claims must generally be submitted within 365 days of the date of service.
• Electronic Payment or Denial: Payers have up to 30 calendar days from electronic receipt to issue payment or a denial or reduction.
• Paper Claims: Standard paper claims have a 60-day payment window.
• Late Payment Interest: Late payments may be subject to 1.5% monthly statutory interest.
• Disputes: A reconsideration request should generally be submitted within 60 days of the original denial or reduction. If the dispute remains unresolved, a formal hearing request may be submitted to the Connecticut Workers' Compensation Commission within the applicable statutory period.

Sources: Connecticut General Statutes §§ 31-294d and 31-280-3; Connecticut Workers' Compensation Commission Administrative Regulations

Pricing Source

• Pricing Databases: Red Book or Medi-Span.

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 Medications: Reimbursed using AWP × 0.681 + $3.29.
• Generic Medications: Reimbursed using AWP × 0.62 + $4.10.
• Lower-of Rule: Final reimbursement is the lowest of the pharmacy's usual and customary charge, the applicable contracted PBM rate, or the state fee schedule amount.

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

Direct Care

• Yes: Under Delaware law and applicable case precedent, an injured worker's right to choose a medical provider does not necessarily include the right to choose a pharmacy. Employers or insurers may direct prescriptions through a preferred PBM network or designated pharmacy.

Sources: Boone v. Syab Services/Capitol Nursing, 2013 WL 3777153 (Del. Supreme Court); 19 Del. C. § 2322

Pre-Authorization

• Yes: Delaware applies state utilization guidelines and medical treatment rules to workers' compensation prescriptions. Non-preferred medications may require prospective approval.

Source: 19 Del. C. § 2322; Delaware Fee Schedule Rules

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable under workers' compensation unless supported by a valid, signed prescription from an authorized treating provider confirming medical necessity.
• Brand OTC Formula: AWP × 0.681 + $3.29.
• Generic OTC Formula: AWP × 0.62 + $4.10.
• Dispensing Fee: Pharmacies may receive the applicable $3.29 brand or $4.10 generic dispensing fee for prescribed OTC medications.

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

Topical Restrictions

• Standard Pricing: Commercially manufactured, non-compounded topical medications are reimbursed using the applicable standard AWP formula.
• Brand Topicals: AWP × 0.681 + $3.29.
• Generic Topicals: AWP × 0.62 + $4.10.
• Missing NDC Information: When the original manufacturer NDC is unavailable, the payer's billing network may use an appropriate equivalent NDC and its associated AWP to determine reimbursement.
• Prior Authorization: Topical products may be subject to Preferred Drug List (PDL) requirements and applicable prior authorization rules.

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

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must be itemized by individual ingredient, with reimbursement based on the applicable NDC and AWP for each component.
• Compounding Fee: Retail pharmacies may receive one $10.00 professional compounding fee per compound prescription.
• Topical Compound Cap: Topical compounded medications are capped at $200.00 per 30-day supply, with prorating applied when appropriate.

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

Timelines

• Electronic Claims: Pharmacy claims submitted through automated PBM systems are transmitted electronically at the point of sale.
• Back-Billed Claims: Manual or paper claims must generally be submitted within 365 days of the date of service.
• Payment or Denial: Clean pharmacy claims must generally be paid, reduced, or formally denied within 30 calendar days of receipt.
• Late Payment Interest: Late payments on undisputed balances may be subject to 1% monthly statutory interest.
• Disputes: Pharmacies or PBM administrators may submit a reconsideration or electronic appeal within 60 days of the initial payment or EOR. If the dispute remains unresolved, a formal Petition to Determine Compensation Due may be filed with the Delaware Industrial Accident Board, subject to applicable statutory filing deadlines.

Sources: 19 Del. C. §§ 2322F(h) and 2361(a)-(b); 19 Delaware Administrative Code 1341, Section 5.0

Pricing Source

• Pricing Databases: Red Book or Medi-Span.

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

State Fee Schedule

• Brand-Name Reimbursement Formula: AWP + $4.18
• Generic Reimbursement Formula: AWP + $4.18
• The "Lower-Of" Contract Override: Payout systems automatically compare calculations against network architecture and default exclusively to the lowest value among: AWP + $4.18, the pharmacy's actual submitted Usual and Customary (U&C) retail charge, or any specifically negotiated PBM contract rate.
• Standard Network Processing Guarantee: All prescriptions processed through a licensed retail pharmacy setting bypass clinic-based repackaging penalties and billing restrictions. Provided the medication is approved by the PBM network and treats the accepted injury, it is billed cleanly under the standard AWP + $4.18 matrix.

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

Direct Care

• No: The employer or insurance carrier is strictly prohibited from directing an injured worker to a specific retail pharmacy or PBM network. The injured employee has an absolute, unrestricted right to choose any licensed retail pharmacy or pharmacist to fill their prescribed medications. Payers are legally forbidden from conditioning coverage, reducing payments, or penalizing an employee based on the specific retail pharmacy they select.

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

Pre-Authorization

• No: Standard open formulary matrix capped at AWP + $4.18 professional fee unless directly contracted under a private PBM tier.

Source: Fla. Stat. 440.13 / DWC Reimbursement Rules

OTC Restrictions

• The Prescription Mandate: Retail pharmacies are strictly prohibited from processing, billing, or collecting reimbursement for any non-legend over-the-counter (OTC) medication or medical supply under a workers' compensation claim unless the injured worker presents a valid, signed written prescription from an authorized treating provider validating medical necessity.
• The Retail Fee Schedule Formula: When an OTC item is backed by a valid prescription, a licensed retail pharmacy processes the line item using AWP + $4.18.
• Full Dispensing Fee Access: Licensed retail pharmacies retain full access to their standard $4.18 professional dispensing fee on all validly prescribed over-the-counter lines.
• Network Formulary Blocks: Automated PBM systems cross-reference prescribed OTC products against the carrier's approved formulary. Common OTC lines, such as standard strength ibuprofen, acetaminophen, or basic topical creams, will process instantly at the counter, while specialized or high-cost non-prescription kits trigger an automated PBM 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

• The Unified Fee Schedule Formula: Standard, commercially manufactured standalone topical medications, including non-compounded prescription creams, gels, ointments, or sprays, filled at a retail pharmacy are adjudicated using AWP + $4.18.
• The Non-Prescription Cream Cap Rule: Certain non-prescription over-the-counter topical creams, ointments, or gels are capped at a maximum of $31.21 for a 30-day supply, prorated based on quantity.
• The Non-Prescription Transdermal Patch Cap Rule: Certain non-prescription over-the-counter transdermal therapeutic patches are capped at a maximum of $72.83 for a 30-day supply, prorated based on quantity.
• The Manufactured Cap Exemption: Commercially manufactured standalone prescription-only (legend) topical products are calculated purely on the standard AWP + $4.18 matrix, provided they clear the carrier's standard prior authorization gates.

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

Compound Restrictions

• The Ingredient Adjudication Mandate: Licensed retail pharmacies processing custom-compounded prescriptions must break down the invoice line-by-line. Reimbursement is calculated using the baseline National Drug Code (NDC) and corresponding Average Wholesale Price (AWP) for each separate, individual active raw ingredient or bulk chemical component.
• The Universal Compound Dispensing Fee Baseline: Single, flat professional handling/compounding fee per multi-ingredient prescription: $4.18.
• The Topical Compound Cost Ceiling: The maximum allowable reimbursement for any multi-ingredient topical compounded formulation filled at a retail pharmacy is strictly capped at $200.00 for a 30-day supply, prorated dynamically based on the exact quantity and volume dispensed.
• Network Compound Prohibition: Multi-ingredient compounds are structurally blocked at the point-of-sale within automated PBM systems and require manual authorization from the carrier. They are permitted only when the treating physician documents that a therapeutically equivalent formulation is not commercially available.

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

Timelines

• Provider Submission Deadline: Florida does not impose a strict statutory timely filing deadline for retail pharmacies to submit initial pharmacy bills, though immediate electronic point-of-sale routing through the PBM clearinghouse is standard.
• Payer Payment/Denial Window: The insurance carrier or TPA must pay, reduce, or formally deny an accurately submitted pharmacy bill within 45 calendar days of receipt.
• Late Payment Penalty: Unpaid undisputed balances past the 45-day window trigger automatic statutory interest penalties. Carriers face administrative state fines of up to $5,000.00 per instance for failing to meet processing and payment standards.
• Dispute Gateways: Tier 1 (State Petition): To contest a bill reduction or denial, the pharmacy or its PBM network administrator must file a Petition for Resolution of Reimbursement Dispute with the Florida Division of Workers' Compensation within 45 days of receiving the carrier's Explanation of Bill Review (EOBR). Tier 2 (Administrative Appeal): Any final disagreement with the administrative determination issued by the Division must be appealed by filing a request for a Chapter 120 Administrative Hearing before an Administrative Law Judge.

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

Pricing Source

Medi-Span

Florida Statutes 440.13(12)(c); Florida Administrative Code Rules 69L-7.020 & 69L-7.740

State Fee Schedule

• Brand-Name Reimbursement Formula: AWP + $4.36 dispensing fee.
• Generic Reimbursement Formula: AWP + $6.53 dispensing fee.
• The "Lower-Of" Adjudication Mandate: Reimbursement calculations are subject to an overriding baseline mandate. Payout systems must cross-reference data and default strictly to the lowest value among: the state's flat fee schedule maximum allowable reimbursement (MAR), the dispensing pharmacy's true submitted Usual and Customary (U&C) retail price, or any pre-negotiated PBM network contract rate.
• Clinic Fee Schedule Disparity: Licensed retail pharmacy entities retain full access to these standard $4.36 and $6.53 professional dispensing fees. Direct-dispensing physician clinics operate under separate packaging, billing, and reimbursement caps set forth in the state fee schedule.

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

Direct Care

• Yes: The employer or insurance carrier holds the legal authority to direct and restrict where an injured worker fills their prescriptions. If the carrier contracts with a specific PBM network or pharmacy management network, the employee is required to utilize an in-network retail pharmacy or authorized mail-order channel.

Sources: Official Code of Georgia Annotated (O.C.G.A.) 34-9-200; Georgia House Bill 1119 (Pharmacy Care Guidelines / Network Rules); Georgia State Board of Workers' Compensation Rule 201

Pre-Authorization

• No: Uses an open database design with built-in PBM network blocks for unbundled compounds or unauthorized brand-name drugs when generic equivalents exist.

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

OTC Restrictions

• The Prescription Mandate: Non-legend over-the-counter (OTC) medications filled at a licensed retail pharmacy are completely non-reimbursable under Georgia workers' compensation lines unless the injured worker presents a signed written prescription from the Authorized Treating Physician (ATP) confirming medical necessity for the accepted injury.
• The Retail Pricing Formula: When an OTC medication is backed by a valid prescription, reimbursement is structured on a cost-plus retail logic: Original Manufacturer AWP + 50%.
• Dispensing Fee Prohibition: Retail pharmacies are strictly barred from collecting their standard $4.36 or 6.53professionaldispensingfeesonanyover-the-counterdrugproduct.The50%percentagemarkupistheexclusivestatutoryallowanceforprocessingnon-prescriptioninventory(0.00 dispensing fee allowed).
• The Invoice Verification Rule: Bill review systems are legally entitled to request and audit a wholesale vendor invoice from the filling provider to verify that the submitted retail price does not artificially exceed the true underlying Original Manufacturer's AWP + 50% baseline.

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

Topical Restrictions

• The Mandatory Category Code Caps Rule: PBM processing software must automatically cross-reference the ingredient profile and cap the 30-day payout values using three specific statutory categories:
  • Category I (Code GA0801): Any topical medication containing a single anti-inflammatory agent or a single local anesthetic agent is strictly capped at $80.00 per 30-day supply.
  • Category II (Code GA0802): Any topical medication containing an anti-inflammatory agent or agents in combination with a local anesthetic agent or agents is strictly capped at $160.00 per 30-day supply.
  • Category III (Code GA0803): Any topical preparation containing any active agent or combination of agents other than standard anti-inflammatories or local anesthetics is strictly capped at $240.00 per 30-day supply.
• The Absolute Maximum Ceiling Rule: No retail prescription line item may ever be reimbursed higher than the absolute state ceiling of $240.00 for a 30-day supply.
• The Dynamic Pro-Ration Mandate: Adjudication engines must mathematically fraction the 30-day fee schedule cap down to match the exact localized gram weight or milliliter volume physically dispensed at the retail counter.
• The Over-the-Counter (OTC) Lesser-Of Override: For over-the-counter manufactured topical items, systems must calculate AWP x 1.50 and restrict final payment to the lesser of that calculated retail value or the corresponding Category I, II, or III flat dollar limits.
• The Auto-Refill Prohibition: PBM network engines must automatically block and deny any sequential, recurring automated refills for topical lines. Every subsequent retail fill requires a new, clinically updated written prescription order from the Authorized Treating Physician (ATP).

Sources: Georgia State Board of Workers' Compensation Medical Fee Schedule, Section IV, Subsection C (Special Rules and Limitations: Topical Medications and Topical Compound Medications); Optum Workers' Compensation Pharmacy Resource Guide (Active 2026 Data Release)

Compound Restrictions

• The Pharmacy Compounding Exemption Baseline: Multi-ingredient compound medications must be processed and billed exclusively by a licensed compounding pharmacy.
• The Ingredient Adjudication Formula: Billing systems must evaluate the custom prescription line-by-line. Each separate, individual active ingredient must be listed by its exact quantity and its corresponding National Drug Code (NDC). The maximum allowable reimbursement is: sum of AWP for each active ingredient x 0.50.
• The Inactive/Missing NDC Penalty: Any component, chemical, or base ingredient that lacks a registered FDA-approved National Drug Code (NDC) is completely non-reimbursable ($0.00 allowed).
• The Compound Active Ingredient Cap: Reimbursement will only be considered for custom-compounded formulations containing three (3) or fewer active ingredients.
• The Retail Pharmacy Compounding Fee Floor: The pharmacy is entitled to a $20.00 compounding fee per prescription invoice.

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

Timelines

• Provider Submission Deadline: Licensed retail pharmacies must submit all initial billing claims to the insurance carrier or their designated PBM network within 1 year (365 days) from the exact date of dispensing, or the right to collection is legally waived.
• Payer Payment/Denial Window: The insurance carrier, TPA, or PBM clearinghouse must issue payment, structural reduction, or a formal written denial within 30 calendar days from the date a properly formatted pharmacy bill is received.
• Late Payment Interest Penalties: Delayed processing triggers automatic statutory financial increases added directly to the pharmacy billing line allowance: undisputed balances paid between 31 and 60 days past receipt incur an automatic 10% penalty. Undisputed balances paid between 61 and 90 days past receipt incur an automatic 20% penalty. Balances unpaid past 90 days accrue additional interest at an annual legal rate of 12%.
• Dispute Gateways: Tier 1 (PBM Audit / Provider Challenge): Any formal disagreement regarding a bill reduction or network contract calculation must be submitted by the pharmacy or its representative to the payer within 120 calendar days of receiving the payment/EOB. Tier 2 (Board Mediation/Hearing): If network remediation fails to resolve the pricing dispute, a formal Form WC-14 must be filed with the Georgia State Board of Workers' Compensation to trigger a state-level mediation conference or an evidentiary hearing before an Administrative Law Judge.

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

Pricing Source

Medi-Span

Sources: Official 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-Name Reimbursement Formula: AWP x 1.40
• Generic Reimbursement Formula: AWP x 1.40
• Professional Dispensing Fee Prohibition: Licensed retail pharmacies are strictly prohibited from adding, billing, or stacking a standalone professional dispensing fee onto the line invoice ($0.00 dispensing fee allowed).
• The "Lower-Of" Adjudication Mandate: Payout software must cross-reference data inputs and default strictly to the lowest value among: AWP x 1.40, the retail pharmacy's true submitted Usual and Customary (U&C) charge to the public, or any lower pre-negotiated PBM network contract rate.
• The Pharmacy Compounding Formula: Custom-compounded medications filled at retail must be processed line-by-line based on the exact fractional gram weight of each underlying ingredient. The calculation engine aggregates the baseline values: Sum of AWP x 1.40 for each individual ingredient with a valid manufacturer NDC. Missing or invalid NDCs flag the individual component line for an immediate $0.00 rejection.
• The General Excise Tax (GET) Allowance: Retail pharmacy entities are legally entitled to separate, itemized reimbursement for any applicable Hawaii General Excise Tax (GET) generated by the transaction, appended directly to the final transaction total.

Sources: Hawaii Revised Statutes (HRS) 386-21.7(a), (b), & (c); Hawaii Administrative Rules (HAR) 12-15-55; Hawaii DLIR Workers' Compensation Supplemental Medical Fee Schedule Guidelines

Direct Care

• No: Under HRS § 386-21(b), Hawaii is a strict "employee choice" state. Employers and insurance carriers do not hold the legal authority to direct initial care or force a worker into a preferred network.
• The Only Exceptions: An employer may only select a provider if the worker is physically incapacitated in an emergency or if the worker explicitly declines to choose a doctor. Even then, the worker retains the right to switch to their chosen physician at any time.

Sources: Hawaii Revised Statutes (HRS) 386-21; Hawaii Administrative Rules (HAR) 12-15-55

Pre-Authorization

• No, with exception of required treatment plans: Initial Care (First 60 Days): Per HAR § 12-15-32(a), pre-authorization and treatment plans are not required for the initial 15 treatments provided during the first 60 calendar days.
• Extended Care (120-Day Cycles): Per HAR § 12-15-32(b), to continue care past 60 days or 15 visits, the physician must submit a formal Treatment Plan. It must be submitted to the employer/carrier at least 7 calendar days before the additional treatment starts.
• Each approved plan covers up to 120 calendar days and a maximum of 15 treatments per block.
• 2026 Legislative Update: SB 2751 / HB 2164, bills designed to cap physician dispensing at 30 days and enforce Pharmacy Benefit Manager (PBM) routing, failed to pass in the 2026 legislative session, leaving physician dispensing practices intact.

Source: Hawaii Rev. Stat. Chapter 386 / June 2026 Session Reports

OTC Restrictions

• The Prescription Mandate: Non-legend, over-the-counter (OTC) medications filled at a licensed retail pharmacy are completely non-reimbursable under Hawaii workers' compensation lines unless accompanied by a signed written prescription from the attending physician confirming a direct therapeutic link to the accepted work injury.
• The Cost-Plus Formula Baseline: When an over-the-counter drug is validly ordered and filled at retail, the traditional legend drug formula is maintained as the maximum allowable ceiling: Original Manufacturer AWP x 1.40.
• The "Lesser-Of" Retail Override: Adjudication software must apply a strict cost-plus logic to retail OTC lines and default to the lower of the AWP x 1.40 ceiling or the pharmacy's true submitted Usual and Customary (U&C) retail price to the general public.
• Dispensing Fee Prohibition: Retail pharmacies are strictly barred from collecting or attaching any separate professional dispensing or handling fees to an over-the-counter product line ($0.00 dispensing fee allowed).
• The General Excise Tax (GET) Allowance: Retail pharmacies are legally permitted to seek separate, itemized reimbursement for any applicable Hawaii General Excise Tax (GET) generated by the over-the-counter transaction, added directly to the line allowance.

Sources: Hawaii Revised Statutes (HRS) 386-21 & 386-21.7; Hawaii Administrative Rules (HAR) 12-15-55

Topical Restrictions

• The Primary Manufacturer Source Rule: All manufactured standalone topical medications, such as non-compounded creams, ointments, gels, or transdermal patches, filled at a retail pharmacy are processed line-by-line using the baseline AWP x 1.40.
• The Repackager Data Scrub: Retail PBM adjudication engines must automatically scrub and strip away any artificial, secondary repackager NDCs or inflated wholesale markups appended by third-party clinic or private-label distributors, defaulting calculation parameters strictly back to the source manufacturer's AWP fields.
• The Missing Source NDC Enforcement Trigger: If a pharmacy or its representative bills a packaged topical item but fails to provide or obscurely passes an "unknown" field for the original underlying manufacturer's NDC data, the claim line constitutes a non-compliant event and must be programmatically rejected ($0.00 allowed).
• The Nonprescription OTC Topical Cost Ceilings: If a retail pharmacy processes a signed prescription for a non-commercially available over-the-counter (OTC) topical product, the traditional AWP x 1.40 formula is entirely capped by the state's rigid, itemized cost-containment limits:
  • Nonprescription Topical Creams or Lotions: Maximum of $30.00 for a 30-day supply.
  • Nonprescription Topical Therapeutic Patches: Maximum of $75.00 for a 30-day supply.
• The Fractional Supply Pro-Ration Mandate: Adjudication platforms must mathematically fraction the 30-day OTC topical maximum caps down to precisely match the fractional gram weight or unit volume physically handed over the counter.
• The General Excise Tax (GET) Allowance: Retail pharmacy entities are legally entitled to separate, itemized reimbursement for any applicable Hawaii General Excise Tax (GET) generated by the topical transaction, which is appended directly to the final line item payout total.

Sources: Hawaii Revised Statutes (HRS) 386-21(c) & 386-21.7(a) & (d); Hawaii Administrative Rules (HAR) 12-15-55; Hawaii House Bill 1648 (Active 2026 Nonprescription Amendment Guidelines)

Compound Restrictions

• The Mandatory Retail Compounding Formula: Multi-ingredient custom compounds processed at a licensed retail pharmacy must be adjudicated exclusively on a line-by-line, ingredient-by-ingredient basis. The maximum allowable reimbursement is calculated by adding the baseline values of each active component: Sum of AWP x 1.40 for each individual active ingredient.
• The Active Ingredient National Drug Code (NDC) Rule: Every single active ingredient utilized in the custom compounding process must be billed with its specific quantity and its unique, registered FDA National Drug Code (NDC). Any chemical, bulk powder, or base substance that lacks a valid manufacturer NDC is non-reimbursable ($0.00 allowed).
• The Missing Source NDC Audit Trigger: If the pharmacy bills a custom compound using a repackaged, secondary, or unmapped ingredient NDC without providing the original underlying manufacturer's source NDC, bill review routing engines must flag the entire compound line for immediate administrative rejection.
• Dispensing and Handling Fee Prohibition: Retail pharmacy providers are strictly barred from collecting or attaching their standard professional dispensing fees, compounding labor fees, or specialized handling fees to a workers' compensation compound invoice. The 140% AWP cap serves as an all-inclusive ceiling ($0.00 compounding fee allowed).
• The General Excise Tax (GET) Allowance: Retail pharmacies are legally entitled to separate, itemized reimbursement for any applicable Hawaii General Excise Tax (GET) generated by the compounding transaction, which is appended directly to the final transaction total.

Sources: Hawaii Revised Statutes (HRS) 386-21.7(a) & (c); Hawaii Administrative Rules (HAR) 12-15-55; Hawaii DLIR Workers' Compensation Supplemental Medical Fee Schedule Guidelines

Timelines

• Provider Submission Deadline: Licensed retail pharmacies must submit all initial billing claims to the insurance carrier, TPA, or designated PBM within 2 years (730 days) from the exact date of dispensing. Failure to submit within this statutory window under Hawaii frameworks acts as a legal waiver of collection rights.
• Payer Payment/Denial Window: The insurance carrier, TPA, or PBM clearinghouse has a mandatory window of 60 calendar days from the exact date of receiving a properly formatted pharmacy bill to either issue full payment or emit an official, itemized written denial notice.
• Late Payment Interest Penalties: If more than 60 calendar days pass between the carrier's receipt of an undisputed pharmacy billing line and the true date of payment, the outstanding balance automatically accrues a statutory interest penalty of 1% per month until paid.
• Dispute Gateways: Tier 1 (State Bill Dispute Request): If a retail pharmacy objects to an adjustment, contractual downcode, or explicit denial of payment, they must file a formal Bill Dispute Request directly with the Director of the Hawaii Department of Labor and Industrial Relations (DLIR). This request must be submitted within 60 calendar days from the postmark of the employer's written objection. Tier 2 (Mandatory Mediation Window): Upon receiving the dispute request, the DLIR Director issues a formal notice triggering a mandatory 31-calendar-day peer negotiation period. The pharmacy and the payer must attempt to resolve the line items independently during this window. Tier 3 (Formal Administrative Review): If negotiation fails after 31 days, either party has a tight window of 14 calendar days to submit a written request to the Director to formally review the dispute and issue a binding administrative decision.

Sources: Haw. Code Regs. 12-15-94(b) & (c); Hawaii Revised Statutes (HRS) 386-21

Pricing Source

Red Book

Sources: HRS 386-21.7(b) & (c); Hawaii Administrative Rules 12-15-55; Hawaii DLIR Medical Fee Schedule Guidelines

State Fee Schedule

• Brand-Name Reimbursement Formula: AWP + $5.00 professional dispensing fee.
• Generic Reimbursement Formula: AWP + $8.00 professional dispensing fee.
• The "Lower-Of" Adjudication Mandate: Adjudication engines must cross-reference data inputs at the point of sale and default strictly to the lowest value among: the calculated statutory AWP fee schedule ceiling, the retail pharmacy's true submitted Usual and Customary (U&C) charge to the public, or any lower pre-negotiated PBM network contract rate.
• The Overriding Therapeutic Ceiling Rule: If a pharmacy fills a product or topical line for which a significantly lower-cost bio-equivalent therapeutic alternative is available on the market, the maximum allowable reimbursement is compressed down to a hard cost-containment cap: 30% above the baseline cost of that lower-cost therapeutic equivalent.

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

Direct Care

• Yes: The employer or insurance carrier retains the explicit statutory right to select, direct, and manage the primary medical network for an injured worker. The employee must treat within this designated network unless a formal administrative change is authorized.
• The Pharmacy Network Carve-Out: While Idaho allows an injured worker to choose their physical retail storefront for medication pick-up under broader pharmacy choice ethics, this choice is completely subject to the payer's contracted PBM network parameters. If a PBM network is established by the carrier, the employee must fill scripts at an in-network retail pharmacy location.

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

Pre-Authorization

• Yes: Adopts the Official Disability Guidelines (ODG) Drug Formulary. "Y" lines clear point-of-sale switches seamlessly; "N" lines are locked pending prior authorization.

Source: Idaho Code 72-432 / Industrial Commission Rules

OTC Restrictions

• The Prescriptive Mandate: Non-legend, over-the-counter (OTC) medications filled at a licensed retail pharmacy are completely non-reimbursable under Idaho workers' compensation lines unless accompanied by a signed written prescription from the attending physician confirming a direct therapeutic link to the accepted work injury.
• The Master Retail Pricing Formula: When an over-the-counter drug is validly ordered and filled at retail, the traditional legend drug pricing format is: Original Manufacturer AWP + $4.00 professional dispensing fee.
• The "Lesser-Of" Retail Override: Adjudication software must apply a strict cost-containment logic to retail OTC lines and default to the lower of the statutory AWP fee schedule ceiling or the pharmacy's true submitted Usual and Customary (U&C) retail price to the general public.
• The Strict 30% Therapeutic Equivalent Cap: If an OTC medication or generic therapeutic equivalent is dispensed when a lower-cost bio-equivalent alternative is commercially available, the billing engine must compress the line allowance. The final payout is strictly restricted to a maximum of 30% above the baseline cost of that lower-cost therapeutic equivalent.
• The Mandatory Original NDC Rule: The retail pharmacy must transmit the active National Drug Code (NDC) of the original manufacturer or source labeler for the OTC item. If a secondary repackager NDC is used or the source labeler field is missing, the system will trigger an administrative gate, allowing the carrier to withhold payment until the true source compliance data is produced.

Sources: Idaho Administrative Code (IDAPA) 17.01.01.803.04(d) & (f) (Medical Fees - Pharmacy and Medicine Rules); Idaho Industrial Commission Medical Fee Schedule Guidelines

Topical Restrictions

• The Primary Manufacturer Source Rule: All manufactured standalone topical medications, such as non-compounded creams, ointments, gels, or transdermal patches, filled at a retail pharmacy are processed line-by-line using the baseline AWP + $5.00 dispensing fee (Brand) or AWP + $8.00 dispensing fee (Generic).
• The Repackager Data Scrub: Retail PBM adjudication engines must automatically cross-reference data inputs at the point of sale to scrub and strip away any artificial, secondary repackager NDCs or inflated wholesale markups appended by third-party private-label distributors, defaulting calculation parameters strictly back to the source manufacturer's AWP fields.
• The Mandatory Payment Withholding Trigger: If a retail pharmacy or its representative bills a packaged topical item but fails to provide or passes an "unknown" field for the original underlying manufacturer's NDC data, the system will trigger an administrative gate, allowing the carrier to withhold payment until the true source compliance data is produced ($0.00 temporary allowance).
• The Strict 30% Therapeutic Equivalent Cap: If a retail pharmacy processes a signed prescription for a topical product, legend or OTC, for which a lower-cost, bio-equivalent therapeutic alternative is available on the market, the billing engine must compress the line allowance. The maximum allowable reimbursement is programmatically restricted to a maximum of 30% above the baseline cost of that lower-cost therapeutic equivalent.
• The Auto-Refill Prohibition: Adjudication platforms must automatically block and deny any sequential, recurring automated refills for retail topical medications under workers' compensation lines. Every subsequent topical fill requires a re-authorized, clinically documented prescription from the attending physician to verify ongoing medical necessity.

Sources: Idaho Administrative Code (IDAPA) 17.01.01.803.04 (Medical Fees - Pharmacy and Medicine Rules); Idaho Industrial Commission Medical Fee Schedule Guidelines

Compound Restrictions

• The Mandatory Retail Compounding Formula: Multi-ingredient custom compounds processed at a licensed retail pharmacy are adjudicated line-by-line and component-by-component. The maximum allowable reimbursement is: Sum of AWP for each individual active ingredient with a valid manufacturer NDC + $5.00 dispensing fee + $2.00 compounding fee.
• The Active Ingredient National Drug Code (NDC) Rule: Every single component substance utilized in the custom compounding process must be billed with its specific quantity and its unique, registered FDA National Drug Code (NDC). Any chemical, bulk powder, or base substance that lacks a valid manufacturer NDC is non-reimbursable ($0.00 allowed).
• The Repackager Data Scrub: Retail PBM adjudication engines must automatically cross-reference component data arrays and strip away any artificial, secondary repackager NDCs or inflated wholesale markups appended by third-party private-label distributors, defaulting calculation parameters strictly back to the original source manufacturer's AWP fields.
• The Mandatory Payment Withholding Provision: If a pharmacy bills a custom compound using a repackaged or secondary ingredient NDC without providing the original underlying manufacturer's source NDC, bill review routing engines are legally authorized to completely withhold all reimbursement until the source compliance data is produced ($0.00 temporary allowance).

Sources: Idaho Administrative Code (IDAPA) 17.01.01.803.04 (Medical Fees - Pharmacy and Medicine Rules); Idaho Industrial Commission Medical Fee Schedule Guidelines

Timelines

• Provider Submission Deadline: Licensed retail pharmacies must submit all initial billing claims to the insurance carrier, TPA, or designated PBM within 1 year (365 days) from the exact date of dispensing. Failure to submit within this statutory window under Idaho frameworks acts as a legal waiver of collection rights.
• Payer Payment/Denial Window: The insurance carrier, TPA, or PBM clearinghouse has a mandatory window of 30 calendar days from the exact date of receiving a properly formatted pharmacy bill to either issue full payment or emit an official, itemized written Preliminary Objection or Request for Clarification.
• The Intermediary Clarification Window: If the payer sends a Request for Clarification within the initial 30 days, the retail pharmacy has 30 calendar days from receipt to submit a written reply. If the pharmacy fails to respond within 30 days, the line item is legally deemed closed out in the payer's favor. Once the pharmacy's reply is received, the payer has an additional 30 calendar days to issue a final payment or release a formal Final Objection.
• Late Payment Interest Penalty: If an undisputed retail billing line remains unpaid past the initial 30-day window, or past 30 days following a valid pharmacy clarification reply, the outstanding balance automatically accrues interest at the statutory rate of 12% per annum, calculated daily at 1% per month, until paid.
• Dispute Gateways: Tier 1 (Formal Motion for Medical Dispute): If a pharmacy objects to a payer's Final Objection, contractual downcode, or structural therapeutic ceiling reduction, it must file a formal Motion for Medical Dispute Resolution directly with the Idaho Industrial Commission (IIC) within 90 calendar days from the date it received the payer's written Final Objection. Tier 2 (Voluntary Mediation Process): After a dispute is filed with the Commission, both parties may mutually agree to halt formal litigation tracks and enter a voluntary, cost-free IIC-facilitated Mediation Conference to settle line items with a compensation consultant. Tier 3 (Formal Administrative Hearing): If mediation fails or is bypassed, either party may file a formal Request for Calendering to transition the dispute into an evidentiary hearing before an IIC Regulatory Referee or Commissioner, generating a binding administrative order.

Sources: Idaho Administrative Code (IDAPA) 17.01.01.803.04 (Prompt Payment & Objections Framework); Idaho Judicial Rules of Practice and Procedure (JRP) Rule 19

Pricing Source

Red Book

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

State Fee Schedule

• Brand-Name Reimbursement Rule: 100% of the provider's true actual and reasonable Usual & Customary (U&C) retail charge to the public.
• Generic Reimbursement Rule: 100% of the pharmacy's submitted Usual & Customary (U&C) charge.
• Physician / Direct Dispensing (Out-of-Pharmacy): $4.18 Dispensing Fee Applies. Under 820 ILCS 305/8.2(a-3) and 50 IAC 9110.90(B), prescriptions filled and dispensed outside of a licensed retail pharmacy, such as direct-dispensing physician clinics, are capped by a statutory fee schedule formula: AWP + $4.18 dispensing fee. AWP or its equivalent as registered by the National Drug Code shall be set forth for that drug on that date as published in Medispan. Repackaged medications: use AWP of underlying medication as identified by NDC from original labeler.

Direct Care

• Yes: If the employer maintains an approved, formal PPP network, the employer has the right to direct care, and the injured worker must choose a primary treating physician from within that network. If the employer does not have an approved PPP, the employee retains complete freedom of choice to select any medical provider.
• If an employee chooses to opt out of the employer's approved PPP network in writing, or if no PPP exists, the employee is statutorily restricted to a "two-choice" limit. The employer is financially liable for all reasonable and necessary medical lines from the employee's first two chosen doctors, plus any subsequent specialists or clinics seen via direct referral from those two primary streams.

Sources: 820 Illinois Compiled Statutes (ILCS) 305/8(a) & 305/8(a-1); 50 Illinois Administrative Code (IAC) 9110.70; Illinois Workers' Compensation Commission (IWCC) Benefit Administration Rules

Pre-Authorization

• No: Open formulary baseline driven by mandatory generic substitution rules and employer-carrier private utilization review filters.

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

OTC Restrictions

• The Prescriptive Mandate: Over-the-counter (OTC) medications filled at a retail pharmacy storefront are completely non-reimbursable under workers' compensation lines unless they are accompanied by a valid, signed written prescription from the attending medical provider establishing a direct therapeutic link to the accepted injury.
• The Retail OTC Pricing Formula: A validly prescribed OTC item defaults to 100% of the pharmacy's submitted Usual & Customary (U&C) retail price or the pre-negotiated PBM network contract rate.
• The Original Manufacturer NDC Tracker: The retail PBM system must capture the exact National Drug Code (NDC) of the original manufacturer or source labeler for the OTC product. Repackaged or private-label store brand NDCs must be cross-referenced back to the source manufacturer data to clear automated auditing gates.

Sources: 820 Illinois Compiled Statutes (ILCS) 305/8.2; 50 Illinois Administrative Code (IAC) 9110.90; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates

Topical Restrictions

• The Retail Commercial Pricing Rule: Standalone commercial topical medications, such as non-compounded creams, ointments, gels, or transdermal patches, filled at a retail pharmacy are processed under: 100% of the pharmacy's submitted Usual & Customary (U&C) public charge or the lower pre-negotiated PBM network contract rate.
• The Repackager NDC Data Scrub: Retail PBM adjudication engines must automatically cross-reference data inputs at the point of sale to scrub and strip away any artificial, secondary repackager NDCs or inflated wholesale markups appended by third-party private-label distributors, defaulting calculation parameters strictly back to the source manufacturer's baseline data fields.
• The Automated Refill Prohibition: PBM adjudication platforms must automatically block and deny sequential, recurring automated refills for retail topical medications under workers' compensation lines. Every subsequent topical fill requires a re-authorized, clinically documented prescription from the attending physician to verify ongoing medical necessity.

Sources: 820 Illinois Compiled Statutes (ILCS) 305/8.2; 50 Illinois Administrative Code (IAC) 9110.90; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates

Compound Restrictions

• The Component-by-Component Retail Pricing Formula: Multi-ingredient custom compounds are adjudicated line-by-line and ingredient-by-ingredient based on 100% of the pharmacy's submitted Usual & Customary (U&C) charge for each fractional weight used, or the pre-negotiated PBM network contract rate.
• The Original Labeler Source Mandate: Every single component substance, bulk chemical, or base cream utilized in the retail compound must be transmitted with its unique, registered FDA National Drug Code (NDC). Any ingredient that lacks a valid manufacturer NDC or represents an unmapped bulk powder is programmatically rejected ($0.00 allowed).
• Prior Authorization Block: All multi-ingredient compounds filled at a retail storefront require mandatory, upfront prior authorization. The retail pharmacy electronic system will trigger a hard rejection at the point of sale if a compound claim is submitted without an active authorization number on file.

Sources: 820 Illinois Compiled Statutes (ILCS) 305/8.2; 50 Illinois Administrative Code (IAC) 9110.90; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates

Timelines

• Pharmacy Billing Submission Threshold: A licensed retail pharmacy storefront must submit point-of-sale electronic claims or paper universal claim forms to the insurance carrier, employer, or contracted Pharmacy Benefit Manager (PBM) within 3 years from the exact date of dispensing to comply with the statutory time limit.
• PBM Adjudication Response Window: For real-time electronic claims routed through an active PBM network clearinghouse, such as Optum, the transaction must be approved or denied instantly at the counter. For paper-submitted, retroactively audited pharmacy invoices, the payer has a mandatory window of 30 calendar days from receipt of a properly documented bill to either issue full payment or emit an official, written Explanation of Benefits (EOB) detailing specific administrative, network, or clinical reasons for a partial or full denial.
• Late Payment Interest Penalty Accrual: If an undisputed retail pharmacy bill or an uncontracted line item remains unpaid past the standard 30-day window, the outstanding balance automatically accrues a statutory late-payment penalty rate of 1.0% per month, compounded at 12% per annum, until paid. The insurance carrier must pay this interest automatically within 30 days of resolving the underlying bill.
• PBM Contract Dispute Escalation Pathway: If a retail pharmacy experiences an unexpected billing reversal, contract audit recoupment, or payment dispute under their commercial PBM network agreement, the pharmacy must exhaust the private PBM's internal credentialing/audit appeal process prior to seeking statutory intervention.
• Formal State Administrative Dispute Gateways: If a retail pharmacy bill is denied by a carrier on an uncontracted paper claim, such as due to a medical necessity dispute or an unaccepted body part, the dispute moves through the standard statutory channels:
  • The Private Civil Action for Interest: If the main bill is paid late but the carrier refuses to remit the accrued 1% monthly interest penalty within 30 days, the pharmacy possesses independent legal standing to file a direct Civil Action in Circuit Court solely to collect the interest due.
  • The Commission Arbitrator Tree: For clinical, usage, or liability disputes, the pharmacy must work in tandem with the injured worker's legal counsel to append the outstanding pharmacy balance as an active medical lien, presenting the dispute during a formal evidentiary hearing before an Illinois Workers' Compensation Commission (IWCC) Arbitrator.

Sources: 820 Illinois Compiled Statutes (ILCS) 305/8.2(d); 50 Illinois Administrative Code (IAC) 9110.70; Illinois Workers' Compensation Commission (IWCC) Timelines and Rules of Practice

Pricing Source

PBM Private Contract Rate Data / Usual & Customary (U&C) Benchmarks / Medi-Span

Sources: 820 Illinois Compiled Statutes (ILCS) 305/8.2; 50 Illinois Administrative Code (IAC) 9110.90; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates

State Fee Schedule

• Brand-Name Reimbursement Rule: 100% of the provider's true, reasonable Usual & Customary (U&C) charge to the general public.
• Generic Reimbursement Rule: 100% of the pharmacy's submitted Usual & Customary (U&C) charge.
• The PBM Contract Override Mandate: If the insurance carrier or employer utilizes an established, contracted Pharmacy Benefit Manager (PBM) network (such as Optum), the automated adjudication engine bypasses the public U&C/reasonable default and enforces the lower, pre-negotiated commercial network contract rate discount grid.
• The "Lesser-Of" Adjudication Gate: Point-of-sale processing software must evaluate lines dynamically and default transactions strictly to the lowest value among: the pharmacy's true submitted Usual and Customary (U&C) charge, the pre-negotiated PBM network contract rate, or any employer-negotiated fee variance.

Sources: Indiana Code (IC) 22-3-3-4; IC 22-3-3-4.5(c); Worker's Compensation Board of Indiana Billing Rules; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates (Updated March 2026)

Direct Care

• Yes: Indiana operates under a strict Employer Direction legal framework. The employer and their workers' compensation insurance carrier possess the absolute statutory authority to select, designate, and direct all medical providers, clinics, and pharmaceutical networks for an injured worker's industrial injury.
• Because the employer controls direction, if the carrier implements a specialized Pharmacy Benefit Manager (PBM) retail network (such as Optum), the injured worker is required to fulfill all outpatient prescription needs at an in-network, participating retail pharmacy storefront.

Sources: Indiana Code (IC) 22-3-3-4(a); Worker's Compensation Board of Indiana Administrative Rules; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Resource Guide

Pre-Authorization

• Yes: Mandates the closed ODG Drug Formulary framework. Point-of-sale networks apply automated prospective blocks on any "N" categorized items lacking prior approval.

Source: Ind. Code 22-3-3-4.7 / Worker's Comp Board Rules

OTC Restrictions

• The Prescriptive Mandate: Over-the-counter (OTC) medications filled at a retail pharmacy storefront are completely non-reimbursable under Indiana workers' compensation lines unless they are accompanied by a valid, signed written prescription from the authorized, directed medical provider establishing a direct therapeutic link to the accepted industrial injury.
• The Retail OTC Pricing Formula: A validly prescribed and authorized OTC item defaults to 100% of the pharmacy's submitted Usual & Customary (U&C) retail price or the pre-negotiated private PBM network contract rate (e.g., Optum's discounted contract grid).
• The Original Manufacturer NDC Tracker: The retail PBM adjudication engine must capture the exact National Drug Code (NDC) of the original manufacturer or source labeler for the OTC product. Repackaged or private-label store brands must be mapped back to the underlying manufacturer source data to clear automated pricing and compliance auditing gates.
• The ODG Formulary Alignment: Prescribed OTC medications must conform to the state's mandatory ODG closed formulary rules. If a specific OTC drug class or formulation is classified as an "N" status item, it remains subject to the mandatory prior authorization gate even if it is an over-the-counter product.

Sources: Indiana Code (IC) 22-3-3-4; IC 22-3-3-4.7; Worker's Compensation Board of Indiana Billing Rules; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates

Topical Restrictions

• The Retail Commercial Pricing Standard: Standalone commercial topical medications (such as non-compounded creams, transdermal ointments, gels, or patch kits) filled at a licensed retail pharmacy storefront are processed under: 100% of the pharmacy's submitted Usual & Customary (U&C) public charge or the lower pre-negotiated private PBM network contract rate.
• The Repackager NDC Data Scrub: The retail PBM adjudication engine must automatically cross-reference data inputs at the point of sale to scrub and strip away any artificial, secondary repackager National Drug Codes (NDCs) or inflated wholesale markups appended by third-party private distributors, defaulting calculation parameters strictly back to the source manufacturer's baseline data fields.
• The Automated Refill Prohibition: PBM adjudication platforms must automatically block and deny sequential, recurring automated refills for retail topical medications under workers' compensation lines. Every subsequent topical fill requires a re-authorized, clinically documented prescription from the directed treating physician to verify ongoing medical necessity.
• The ODG Status Alignment Rule: Topical agents must strictly conform to Indiana's mandatory ODG closed formulary rules. If a topical prescription is classified under an "N" status code, it remains subject to a hard block at the point of sale unless prior authorization has been explicitly secured through a formal Utilization Review (UR) track.

Sources: Indiana Code (IC) 22-3-3-4; IC 22-3-3-4.7; Worker's Compensation Board of Indiana Medical Fee Schedule Guidelines; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Network Contract Rates

Compound Restrictions

• The Component-by-Component Retail Pricing Formula: A multi-ingredient prescription compound filled at a retail pharmacy is priced line-by-line and substance-by-substance. The automated adjudication engine calculates reimbursement based on 100% of the pharmacy's submitted Usual & Customary (U&C) charge for each ingredient's fractional metric weight, or the pre-negotiated private PBM network contract rate.
• The Original Labeler NDC Mandate: To secure payment under Indiana's strict data auditing provisions, every single component substance, active pharmaceutical ingredient (API), bulk chemical, or vehicle base utilized in the compound must be transmitted with its unique, registered National Drug Code (NDC). Any ingredient field that is omitted, unmapped, or contains an invalid NDC must be programmatically compressed to a $0.00 allowance.
• The Pharmacy Compounding Fee Cap: A single, flat compounding labor fee of $10.00 is allowed per multi-ingredient prescription.
• Prior Authorization Block & ODG Alignment: All custom multi-ingredient compounds require mandatory, upfront prior authorization. Because compounds are automatically classified as non-preferred "N" status items under the state's ODG closed formulary rules, the pharmacy electronic clearinghouse will trigger an immediate hard rejection at the point of sale unless an active authorization number is passed.

Sources: Indiana Code (IC) 22-3-3-4; IC 22-3-3-4.7; Worker's Compensation Board of Indiana Billing Rules; Optum Workers' Compensation Pharmacy Fee Schedule & PBM Adjudication Resource Guide (Updated March 2026)

Timelines

• Pharmacy Billing Submission Threshold: A licensed retail pharmacy storefront must submit point-of-sale electronic claims or paper universal claim forms to the employer, insurance carrier, or contracted Pharmacy Benefit Manager (PBM) within 120 calendar days from the exact date of dispensing to remain within the Worker's Compensation Board's billing criteria guidelines.
• PBM Adjudication Response Window: For real-time electronic claims routed through an active PBM network (such as Optum), the transaction must be approved, discounted, or denied instantly at the counter. For paper-submitted or retroactively audited pharmacy invoices, the payer has a mandatory window of 90 calendar days from the date of receiving the properly documented bill to either issue payment or emit an official, written Notification of Contest (denial) outlining the specific regulatory reasons for non-payment.
• The Billing Data Request Tolling Rule: If the payer issues a formal request to the retail pharmacy for additional documentation or records supporting the dispensed lines, the 90-day adjudication clock is completely tolled (paused). The clock resumes only once the pharmacy delivers the requested data to the payer.
• Late Payment Interest Penalty Accrual: If an undisputed retail pharmacy bill or an uncontracted line item remains unpaid past the statutory prompt-pay window, interest automatically accrues on the delinquent amount. Interest begins accruing on the 31st day following receipt for an electronically filed claim, or on the 46th day following receipt for a paper-filed claim, at the simple interest rate set by state Medicaid tracking provisions.
• PBM Contract Dispute Escalation Pathway: If a retail pharmacy experiences an unexpected billing reversal, contract audit recoupment, or payment dispute under their commercial PBM network agreement, the pharmacy must exhaust the private PBM's internal credentialing/audit appeal process prior to seeking statutory intervention.
• The Formal Board Dispute Window: If private contract remedies or good-faith negotiations fail to resolve an uncontracted retail pharmacy dispute, the provider must file a formal Application for Adjustment of Claim for Provider Fee with the Worker's Compensation Board of Indiana. This application must be filed within two (2) years of receiving the initial written communication or Explanation of Review (EOR) from the employer or insurance carrier denying the fee.

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

Pricing Source

• PBM Private Contract Rate Data / Usual & Customary (U&C) Benchmarks / Medi-Span

Sources: Indiana Code (IC) 22-3-3-4; IC 22-3-3-4.5; IC 22-3-3-5; 631 Indiana Administrative Code (IAC) 1-1-28; Worker's Compensation Board of Indiana 2026 Provider Guidance Memo

State Fee Schedule

• Brand-Name Reimbursement Rule: 100% of the provider's true, reasonable Usual & Customary (U&C) charge to the general public.
• Generic Reimbursement Rule: 100% of the pharmacy's submitted Usual & Customary (U&C) charge, provided it reflects local geographic market parameters.
• The PBM Contract Override Mandate: If the insurance carrier or employer implements an established, contracted Pharmacy Benefit Manager (PBM) network (such as Optum), the automated adjudication engine bypasses the public U&C "reasonable cost" fallback and enforces the lower, pre-negotiated commercial network contract rate discount grid.
• The "Lesser-Of" Adjudication Gate: Point-of-sale processing software must evaluate transactions dynamically and default lines strictly to the lowest value among: the pharmacy's submitted Usual and Customary (U&C) charge, the pre-negotiated PBM network contract rate, or 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 is a strict Employer Direction state. The employer possesses the absolute statutory right to choose, direct, and designate the medical providers, clinical care coordinators, and pharmaceutical networks for an employee's covered industrial injury.
• If an injured worker chooses to bypass the employer's designated PBM path and fills a non-emergency prescription at an unauthorized or out-of-network retail pharmacy storefront, the employer and insurance carrier are legally empowered to completely deny payment for the resulting pharmacy billing lines.

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

Pre-Authorization

• No: Iowa does not use a state-mandated pharmacy fee schedule or centralized closed formulary. Outbound storefront entries must be "reasonable."

Source: Iowa Code 85.27 / Workers' Compensation Division

OTC Restrictions

• The Prescriptive Mandate: Over-the-counter (OTC) medications purchased at a retail pharmacy storefront are completely non-reimbursable under Iowa workers' compensation lines unless they are accompanied by a valid, signed written prescription from the authorized, directed treating provider establishing a direct therapeutic link to the accepted industrial injury.
• The Retail OTC Pricing Formula: Validly prescribed and authorized OTC item defaults to 100% of the pharmacy's submitted Usual & Customary (U&C) retail price or the pre-negotiated private PBM network contract rate (e.g., Optum's discounted contract grid).
• The Original Manufacturer NDC Tracker: The retail PBM adjudication engine must capture the exact National Drug Code (NDC) of the original manufacturer or source labeler for the OTC product. Repackaged or private-label store brands must be mapped back to the underlying manufacturer source data to clear automated pricing and compliance auditing gates.
• Clinical Necessity Auditing: In the absence of a rigid state formulary, the carrier or its PBM utilizes evidence-based utilization standards to screen OTC submissions. Automated reviews check to ensure the therapeutic class of the OTC drug aligns directly with the nature of 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

Topical Restrictions

• The Retail Commercial Pricing Standard: Standalone commercial topical medications (such as non-compounded creams, transdermal ointments, gels, or patch kits) filled at a licensed retail pharmacy storefront are processed under the standard Iowa retail layout: 100% of the pharmacy's submitted Usual & Customary (U&C) public charge or the lower pre-negotiated private PBM network contract rate (e.g., Optum's discounted contract grid).
• The Repackager NDC Data Scrub: The retail PBM adjudication engine must automatically cross-reference data inputs at the point of sale to scrub and strip away any artificial, secondary repackager National Drug Codes (NDCs) or inflated wholesale markups appended by third-party private distributors, defaulting calculation parameters strictly back to the source manufacturer's baseline data fields.
• The Automated Refill Prohibition: PBM adjudication platforms must automatically block and deny sequential, recurring automated refills for retail topical medications under workers' compensation lines. Every subsequent topical fill requires a re-authorized, clinically documented prescription from the directed treating physician to verify ongoing medical necessity.
• Clinical Necessity Auditing: In the absence of a rigid state formulary, the carrier or its PBM utilizes evidence-based utilization standards to screen topical submissions. Automated reviews check to ensure the therapeutic class of the topical drug aligns directly with the nature of 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

• The Component-by-Component Retail Pricing Formula: A multi-ingredient prescription compound filled at a retail pharmacy is priced line-by-line and substance-by-substance. The automated adjudication engine calculates reimbursement based on 100% of the pharmacy's submitted Usual & Customary (U&C) charge for each ingredient's fractional metric weight, or the pre-negotiated private PBM network contract rate.
• The Original Labeler NDC Mandate: To secure payment under standard electronic data auditing provisions, every single component substance, active pharmaceutical ingredient (API), bulk chemical, or vehicle base utilized in the compound must be transmitted with its unique, registered National Drug Code (NDC). Any ingredient field that is omitted, unmapped, or contains an invalid NDC will be programmatically compressed to a $0.00 allowance.
• The Pharmacy Compounding Fee Framework: In the absence of a restrictive state statutory cap specific to workers' compensation lines, a single, flat compounding labor/professional fee is evaluated against local market parameters or bounded by the private PBM network's contract rules (such as Optum's commercial network caps).
• Prior Authorization Block & Clinical Review: Multi-ingredient custom compounds face strict upfront prior authorization gates. Because compounds lack standard, single-source clinical data, the pharmacy electronic clearinghouse will trigger an immediate hard rejection at the point of sale unless an active clinical authorization number is passed by the carrier or its 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: A licensed retail pharmacy storefront must submit point-of-sale electronic claims or paper universal claim forms to the payer within 365 calendar days from the date of dispensing to remain within timely billing guidelines.
• Payer Payment/Denial Window: For real-time electronic claims routed through an active PBM network (such as Optum), transactions are approved, discounted, or denied instantly at the counter. For paper or retroactively audited pharmacy invoices, the payer has a mandatory window of 30 calendar days from receipt to either issue payment or emit an official Explanation of Review (EOR) detailing a denial.
• The Employee Hold-Harmless Provision: The employer controls care direction and must hold the injured employee completely harmless for the cost of that care. If a pharmacy bill is denied or reduced, the pharmacy is statutorily barred from balance billing the injured worker while the claim is active.
• Late Payment Interest Penalty: If an undisputed retail pharmacy bill remains unpaid past the 30-day prompt-pay window, interest automatically accrues on the delinquent amount. The rate is tied directly to the state's variable index (the five-year U.S. Treasury bond rate plus an additional 2.0%), beginning on the 31st day post-receipt until paid.
• PBM Contract Dispute Escalation: If a retail pharmacy experiences a billing reversal, contract audit recoupment, or payment dispute under their commercial PBM network agreement, the pharmacy must exhaust the private PBM's internal appeal process prior to seeking state intervention.
• Formal State Administrative Dispute Window: If private contract remedies fail to resolve an uncontracted retail pharmacy dispute, the provider must file a formal Petition for a Contested Case Proceeding directly with the Iowa Workers' Compensation Commissioner under Iowa Administrative Code (IAC) rule 876 4.1. This formal action must be filed within two (2) years from the exact date of the underlying injury (or within three (3) years from the date of 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 Rate Data / Usual & Customary (U&C) Benchmarks / 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 Formula: AWP x 0.90 + $3.00 Dispensing Fee.
• Generic Reimbursement Formula: AWP x 0.85 + $5.00 Dispensing Fee.
• The PBM Contract Override Mandate: When an insurance carrier utilizes a contracted Pharmacy Benefit Manager (PBM) network (such as Optum), the automated transaction processor bypasses the public statutory fee schedule cap and binds the settlement exclusively to the lower, pre-negotiated commercial network discount template.
• The "Lesser-Of" Adjudication Gate: Point-of-sale processing software must evaluate transactions dynamically and default lines strictly to the lowest value among: the statutory AWP-minus-percentage formula, the storefront's submitted Usual & Customary (U&C) price to the general public, or the pre-negotiated commercial PBM network contract 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 operates under a strict Employer Direction legal framework. The employer and their insurance carrier possess the absolute statutory authority to select, designate, and direct the medical providers, clinical care coordinators, and pharmacy networks for an injured worker's industrial injury.

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

Pre-Authorization

• Yes: Strictly utilizes the ODG Appendix A Drug Formulary. Non-preferred or "N" status lines face a prospective pre-certification requirement.

Source: Kan. Stat. Ann. 44-510j / K-DOL Rules

OTC Restrictions

• The Prescriptive Mandate: Over-the-counter (OTC) medications purchased at a retail pharmacy storefront are completely non-reimbursable under Kansas lines unless they are accompanied by a valid, signed written prescription from the authorized, directed treating provider establishing a direct therapeutic link to the accepted industrial injury.
• The AWP Maximum Fee Pricing Formula: AWP x 0.85 + $5.00 Generic Dispensing Fee.
• The Original Manufacturer NDC Tracker: The retail PBM adjudication engine must capture the exact National Drug Code (NDC) of the original manufacturer or source labeler for the OTC product. Repackaged or private-label store brands must be mapped back to the underlying manufacturer source data to clear automated pricing and compliance auditing gates.
• The ODG Formulary Alignment: Prescribed OTC medications must conform to the state's mandatory ODG closed formulary rules. If a specific OTC drug class or formulation is classified as an "N" status item, it remains subject to the mandatory prior authorization gate even if it is an over-the-counter product.

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

• The Retail Commercial Pricing Formula: AWP x 0.90 + $3.00 Dispensing Fee for brand items, or AWP x 0.85 + $5.00 Dispensing Fee for generic items.
• The $200 Topical Pricing Cap: The maximum allowable reimbursement (MAR) for any topical drug line is programmatically capped at the lesser of $200.00 for a 30-day supply (prorated dynamically if the supply is for fewer or more than 30 days) or the standard AWP-minus-percentage formula allowed under the general fee schedule.
• The Repackager NDC Data Scrub: The retail PBM adjudication engine must automatically cross-reference data inputs at the point of sale to identify and strip away any secondary repackager National Drug Codes (NDCs) or inflated wholesale markups appended by private labelers, defaulting calculation parameters strictly back to the source manufacturer's baseline data fields.
• The ODG Formulary Prior Authorization Gate: All retail topical treatments are subject to the state's mandatory ODG closed formulary rules. If a topical agent or any underlying active ingredient carries an "N" status designation, it will trigger an immediate point-of-sale rejection and requires a formal, approved prior authorization number before the pharmacy can dispense it.
• The Automated Refill Prohibition: PBM adjudication platforms must automatically block and deny sequential, recurring automated refills for retail topical medications under Kansas lines. Subsequent topical fills require a re-authorized, clinically documented prescription from the directed treating physician to verify ongoing 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

• The Component-by-Component Retail Pricing Formula: AWP x 0.85 + $5.00 Generic Dispensing Fee.
• The Original Labeler NDC Mandate: To secure payment under standard electronic data auditing provisions, every single component substance, active pharmaceutical ingredient (API), bulk chemical, or vehicle base utilized in the compound must be transmitted with its unique, registered National Drug Code (NDC). Any ingredient field that is omitted, unmapped, or contains an invalid NDC will be programmatically compressed to a $0.00 allowance.
• The Pharmacy Compounding Fee Framework: A single, flat compounding labor or professional fee is added to the multi-ingredient total, evaluated against local market parameters or bounded by the private PBM network's contract rules (such as Optum's commercial network caps).
• The Mandatory Prior Authorization Hard Block: Multi-ingredient custom compounds face strict upfront prior authorization gates under Kansas law. Because compounds lack a single-source clinical baseline and are treated as non-preferred items, the pharmacy electronic clearinghouse will trigger an immediate hard rejection at the point of sale unless an active clinical authorization number is passed by the carrier or its PBM.

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: A licensed retail pharmacy storefront must submit point-of-sale electronic claims or paper universal claim forms to the payer within 365 calendar days from the date of dispensing to remain within timely billing guidelines.
• Payer Payment/Denial Window: For real-time electronic claims routed through an active PBM network (such as Optum), transactions are approved, discounted, or denied instantly at the counter. For paper or retroactively audited pharmacy invoices, the payer has a mandatory window of 30 calendar days from receipt to either issue payment or emit an official Explanation of Review (EOR) detailing a denial.
• The Provider Reconsideration Gate: If a retail pharmacy disagrees with an audit reversal or manual bill reduction emitted on the payer's EOR, the pharmacy or its billing agent must formally submit a written request for reconsideration back to the payer within 30 calendar days of receiving the dispute notice.
• The Informal Hearing Trigger: If a provider sends a pharmacy bill and receives no response within 30 days, sends a second bill, and receives no response within 60 days of the first submission, the provider may apply for an Informal Hearing before the Director of the Workers' Compensation Division.
• The Employee Hold-Harmless Provision: When medical care is directed and authorized by the employer, the employee must be held completely harmless. The pharmacy is statutorily barred from balance billing or attempting to collect payment shortfalls from the injured worker while the claim is active.
• The Formal Judicial Review Deadline: If the parties are unable to reach a settlement after the informal phase, the hearing officer will enter an administrative order. Any party wishing to appeal this final medical fee determination must file a notice of appeal to the Workers Compensation Appeals Board within 10 calendar days of the decision's issuance.

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

Pricing Source

• PBM Private Contract Rate Data / Medi-Span or First Databank (AWP Percentages)

Sources: Kansas Statutes Annotated (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 Formula: AWP x 0.90 + $5.00 Dispensing Fee.
• Generic Reimbursement Formula: AWP x 0.85 of the lowest priced equivalent drug product + $5.00 Dispensing Fee.
• The Flat Professional Dispensing Fee Rule: Kentucky administrative law mandates that a licensed pharmacist receive a single, uniform handling allowance of exactly $5.00 for every prescription line filled.
• The "Lesser-Of" Adjudication Gate: Point-of-sale processing software must evaluate transactions dynamically and default lines strictly to the lowest value among: the statutory AWP-minus-percentage formula, the storefront's submitted Usual & Customary (U&C) price to the general public, or any lower pre-negotiated commercial PBM network contract rate.
• Kentucky House Bill (HB) 627 revises the state's Motor Vehicle Reparations Act by tying Auto Personal Injury Protection (PIP) 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 classified as an Employee Choice jurisdiction for primary clinical care under Kentucky Revised Statutes (KRS) 342.020(4). The injured worker possesses the foundational right to pick their initial designated treating provider. However, the state grants employers and insurance carriers strong mechanisms to control outpatient retail pharmacy distribution.
• If an employer utilizes a state-certified Workers' Compensation Managed Health Care Plan under 803 KAR 25:110 (such as Optum's certified Kentucky network), the injured workers initial choice of a treating medical provider must be made exclusively from within that specific networks approved medical directory.

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: Mandates the use of the closed ODG Drug Formulary. Point-of-sale retail networks run automated blocks on non-preferred drug classes.

Source: KRS Chapter 342 / Department of Workers' Claims

OTC Restrictions

• The Prescriptive Mandate: Over-the-counter (OTC) medications purchased at a retail pharmacy storefront are completely non-reimbursable under Kentucky lines unless they are accompanied by a valid, signed written prescription from the authorized, directed treating provider establishing a direct therapeutic link to the accepted industrial injury.
• The AWP Maximum Fee Pricing Formula: Kentucky applies its strict statutory pharmacy fee schedule calculation to validly prescribed OTC lines filled at a retail storefront, calculated as: 85% of the AWP of the lowest priced equivalent drug product + $5.00 Dispensing Fee.
• The Uniform Dispensing Fee Allowance: Because the OTC product is being billed and distributed by a licensed retail pharmacist, the transaction qualifies for the state's standardized professional handling allowance of exactly $5.00, mirroring standard generic script rules.
• The Original Manufacturer NDC Tracker: The retail PBM adjudication engine must capture the exact National Drug Code (NDC) of the original manufacturer or source labeler for the OTC product. Repackaged or private-label store brands must be mapped back to the underlying manufacturer source data to clear automated pricing and compliance auditing gates.
• The ODG Formulary Alignment: Prescribed OTC medications must conform to the state's mandatory ODG closed formulary rules under 803 KAR 25:270. If a specific OTC drug class or formulation is classified as an "N" status item, it remains subject to the mandatory prior authorization gate even if it is an over-the-counter product.

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

• The Retail Topical Pricing Formula: Standalone commercial topical medications (such as non-compounded prescription creams, transdermal ointments, gels, or patch kits) filled at a licensed retail pharmacy storefront are capped based on the standard 803 KAR 25:092 pharmacy calculations: AWP x 0.90 + $5.00 Dispensing Fee for Brand-name items, or AWP x 0.85 of the lowest priced equivalent drug product + $5.00 Dispensing Fee for Generic items.
• The Repackager NDC Data Scrub: To eliminate arbitrary cost markups on specialized transdermal lines, the retail PBM adjudication engine must automatically cross-reference data fields at the point of sale. The processing system will strip away secondary repackager National Drug Codes (NDCs) and private labeler wholesale pricing layers, recalculating the AWP baseline strictly against the original manufacturer's raw data fields.
• The ODG Formulary Prior Authorization Gate: Retail topical treatments are strictly bound to the state's mandatory ODG closed formulary rules under 803 KAR 25:270. If a topical formulation or any of its primary active agents is classified as an "N" status item, the transaction clearinghouse will trigger an immediate hard block at the pharmacy counter, requiring a formal Utilization Review approval code before the product can be handed to the injured worker.
• The Automated Refill Prohibition: PBM network platforms are programmatically directed to block and deny sequential, automated refills for retail topical medications under Kentucky lines. Subsequent topical distributions require a new, verified electronic or paper prescription from the authorized treating physician to document ongoing clinical necessity and prevent drug diversion.

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

Compound Restrictions

• The Component-by-Component Retail Pricing Formula: Multi-ingredient prescription compounds filled at a retail pharmacy storefront are priced line-by-line and substance-by-substance under 803 KAR 25:092 Section 2(7). The maximum allowable reimbursement (MAR) is calculated based on each active ingredient's fractional metric weight using the standard formula: 85% of the AWP of the lowest priced equivalent drug product + $5.00 Flat Dispensing Fee.
• The Original Labeler NDC Mandate: To secure payment on any compound, the billing pharmacy must submit the original National Drug Code (NDC) of the underlying manufacturer or raw bulk chemical distributor for each constituent item. Under state rules, an NDC assigned by a secondary repackager or the compounding pharmacy itself cannot be used; if an ingredient's original manufacturer NDC is missing, the system will programmatically default its individual calculation to the AWP of the lowest-priced therapeutic equivalent.
• The Single-Fee Compounding Labor Rule: Pharmacies are restricted to a single $5.00 professional dispensing fee for the entire compounded product. They are statutorily barred from stacking separate handling fees or adding customized compounding labor line markups onto the invoice.
• The Mandatory Prior Authorization Hard Block: Custom compounds face strict upfront utilization review gates under 803 KAR 25:270. Because compounds lack an FDA single-source clinical baseline, the pharmacy's point-of-sale electronic system will trigger an immediate hard rejection unless a valid carrier authorization number is active in the system.

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 Submission Deadline: All medical and pharmaceutical service providers are bound to a strict initial statutory timely filing window. A retail pharmacy storefront must submit its completed invoice to the payer within 45 calendar days from the date of dispensing. The Kentucky Supreme Court strictly enforces this window, meaning late submissions are subject to a permanent non-reimbursable default.
• Payer Payment/Denial Window: For standard electronic transactions routed through a real-time point-of-sale network (such as Optum), pricing approval or clinical rejection occurs instantly. For paper invoices or manual retail billing overrides, the carrier has a mandatory window of 30 calendar days from the receipt of the statement to either tender payment or issue a formal written denial.
• The Medical Bill Audit Reconsideration Gate: If a retail pharmacy storefront experiences an adverse retroactive audit reduction or a line-item fee calculation dispute, the pharmacy or its contract clearinghouse must exhaust internal administrative remedies by filing a request for a Medical Bill Audit (MBA) Reconsideration within 30 calendar days of receiving the carrier's Explanation of Review (EOR).
• The Formal Medical Fee Dispute Trigger Window: If the pharmacy cannot resolve a pricing or payment shortfall through the carrier's internal reconsideration channel, the pharmacy must escalate the conflict by filing a formal Form 112 (Medical Fee Dispute) with the state within 30 calendar days of receiving the carrier's final audit determination.
• The Employee Hold-Harmless Provision: When a retail prescription is generated under an active, authorized claim, the storefront is statutorily barred from balance billing or collecting payment shortfalls from the injured worker.
• The Administrative Appeal Process: Once a Form 112 is active, the dispute is evaluated by an Administrative Law Judge (ALJ) who will enter a formal cost-containment order. Any party wishing to appeal the ALJ's final administrative fee determination must submit a notice of appeal to the Workers' Compensation Board within 30 calendar days.

Sources: Kentucky Revised Statutes (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: Kentucky Revised Statutes (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 Formula: AWP x 1.10 + $11.81 Dispensing Fee.
• Generic Reimbursement Formula: AWP x 1.40 + $11.81 Dispensing Fee.
• The Medicaid-Linked Dispensing Fee Rule: Pursuant to Louisiana administrative rules, the professional handling allowance for workers' compensation retail transactions is tied to the official state Medicaid professional dispensing fee in effect. This locks the baseline handling fee at exactly $11.81 per prescription line for both brand and generic drug classes filled by a licensed pharmacist.
• The "Lesser-Of" Adjudication Gate: Point-of-sale processing software must evaluate incoming transactions dynamically and default retail lines strictly to the lowest value among: the statutory AWP-plus-percentage formula, the storefront's submitted Usual & Customary (U&C) price charged to the general public, or any lower pre-negotiated commercial PBM network contract rate.

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

Direct Care

• No: Employers and insurance carriers are statutorily prohibited from forcing an injured worker to use a specific retail chain, mail-order provider, or a proprietary Pharmacy Benefit Manager (PBM) network program. If an employee prefers a local independent pharmacy over an insurer's preferred corporate network, the worker's choice overrides carrier preference.

Sources: Louisiana Revised Statutes (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: Open baseline monitored by retrospective necessity reviews. 2026 Legislative Update: House Bill 1047 was introduced to explicitly exclude prescription drugs from authorization requests, codifying that scripts do not require prior clearance.

Source: La. Rev. Stat. 23:1203 / 2026 House Bill 1047

OTC Restrictions

• The Prescriptive Mandate: Over-the-counter (OTC) medications supplied at a retail pharmacy storefront are completely non-reimbursable under Louisiana workers' compensation lines unless they are accompanied by a valid, signed written prescription from the authorized treating medical provider that establishes a direct therapeutic link to the accepted industrial injury.
• The $50.00 Pre-Authorization Gate: Mirroring standard prescription lines under La. R.S. 23:1142(B), any prescribed OTC item carrying a total calculated fee schedule cost exceeding $50.00 must be formally submitted for prior authorization using Form LWC-WC-1010. If a pharmacy fills an OTC item exceeding this limit without prior written carrier consent, the payer's statutory liability is compressed to an absolute cap of exactly $50.00, and the remaining balance cannot be collected.
• The Statutory Pricing Formula Baseline: Validly prescribed and authorized OTC lines dispensed at a retail counter are capped under La. Admin. Code tit. 40, I-2907 at the standard generic pharmacy fee schedule calculation, defined as: AWP x 1.40 + $11.81 Dispensing Fee.
• The Uniform Dispensing Fee Allowance: Because the OTC product is being billed, cataloged, and distributed by a licensed retail pharmacist rather than a clinic doctor, the transaction qualifies for the state's standardized, Medicaid-linked professional handling allowance of exactly $11.81, matching standard generic script rules.
• The Original Manufacturer NDC Tracker: The retail PBM adjudication engine must capture the exact National Drug Code (NDC) of the original manufacturer or source labeler for the OTC product. Repackaged or private-label store brands must be mapped back to the underlying manufacturer source data to clear automated pricing and compliance auditing gates.

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

Topical Restrictions

• The Retail Topical Pricing Formula: Standalone commercial topical medications (such as non-compounded prescription creams, transdermal ointments, gels, or patch kits) filled at a licensed retail pharmacy storefront are capped based on the standard La. Admin. Code tit. 40, I-2907 pharmacy calculations: AWP x 1.10 + $11.81 Dispensing Fee for Brand-name items, or AWP x 1.40 + $11.81 Dispensing Fee for Generic items.
• The $50.00 Pre-Authorization Cap: In strict accordance with La. R.S. 23:1142(B), any topical medication or transdermal patch filled at a retail counter that carries a calculated fee schedule cost exceeding $50.00 requires a mandatory, prospective prior authorization code via an LWC-WC-1010 Form. If a pharmacy fills a topical line item exceeding this limit without prospective carrier approval, the payer's statutory liability drops to an absolute flat cap of exactly $50.00.
• The Repackager NDC Data Scrub: To eliminate arbitrary cost markups on specialized transdermal lines, the retail PBM adjudication engine must automatically cross-reference data fields at the point of sale. The processing system will strip away secondary repackager National Drug Codes (NDCs) and private labeler wholesale pricing layers, recalculating the AWP baseline strictly against the original manufacturer's raw data fields under La. Admin. Code tit. 40, I-2905.
• The Automated Refill Prohibition: PBM network platforms are programmatically directed to block and deny sequential, automated refills for retail topical medications under Louisiana lines. Subsequent topical distributions require a new, verified electronic or paper prescription from the authorized treating physician to document ongoing clinical necessity and prevent drug diversion.

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

Compound Restrictions

• The Generic Formula Compound Rule: In strict accordance with La. Admin. Code tit. 40, I-2907(D), multi-ingredient prescription compounds dispensed by a retail pharmacy storefront are priced line-by-line and substance-by-substance utilizing the exact same statutory reimbursement formula applied to generic drugs. Each constituent active ingredient is calculated using its fractional metric weight based on the formula: AWP x 1.40 + $11.81 Dispensing Fee.
• The Single-Fee Compounding Labor Cap: Bill review processing engines are programmatically directed to restrict the compound invoice to a single $11.81 professional dispensing fee for the entire completed prescription. Retail storefronts are statutorily barred from stacking separate handling allowances for individual ingredients or attaching custom compounding labor surcharges.
• The Original Labeler NDC Mandate: To secure reimbursement, the billing retail pharmacy must transmit the active National Drug Code (NDC) of the original manufacturer or raw bulk chemical provider for every individual component within the mix. Under state cost-containment audits, repackager or pharmacy-assigned dummy NDCs will be programmatically rejected, compressing the missing element's value to a $0.00 allowance.
• The $50.00 Pre-Authorization Gate: Because custom compounds almost always exceed the state's minor non-authorization cost threshold, they require a mandatory, prospective prior authorization code via an LWC-WC-1010 Form before dispensing. If a retail pharmacist fills a compound exceeding $50.00 without prospective carrier approval, the payer's statutory liability drops to an absolute flat cap of exactly $50.00.

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

Timelines

• Pharmacy Billing Submission Deadline: In accordance with standard Louisiana medical billing rules, a licensed retail pharmacy storefront must submit its properly coded invoice to the employer or workers' compensation insurance carrier within 365 calendar days (1 year) from the exact date of dispensing to comply with timely filing limits. Late submissions are subject to a permanent non-reimbursable default.
• Payer Payment/Denial Window: The insurance carrier or self-insured employer must process the retail bill within a mandatory window. For standard electronic transactions routed through a real-time point-of-sale network, pricing verification or clinical rejections are instantaneous, but the formal clearinghouse payment deadline is 30 calendar days. For paper invoices, the payer has 60 calendar days from receipt to issue payment or a formal written denial.
• The Medical Director Authorization Appeal (Form 1009): If a retail medication line item exceeding $50.00 is denied or modified by the carrier's Utilization Review team on an LWC-WC-1010 form, the aggrieved pharmacy or prescribing provider must file a formal Form LWC-WC-1009 (Disputed Claim for Medical Treatment) with the OWC Medical Director within 15 calendar days of receiving the denial.
• The Medical Director Review Window: Upon receipt of the completed Form 1009 package, the OWCA Medical Director evaluates the medical necessity of the prescription against the Louisiana Medical Treatment Guidelines. The Medical Director must issue a binding administrative determination within 30 calendar days.
• The Employee Hold-Harmless Provision: In strict compliance with Louisiana statutory protocols, when a retail prescription is generated under an active, authorized claim, the storefront is statutorily barred from balance billing or attempting to collect payment shortfalls from the injured worker.
• The Judicial District Appeal Gate (Form 1008): If the retail pharmacy or the carrier disagrees with the OWCA Medical Director's administrative ruling, they must seek formal judicial review. Under La. R.S. 23:1203.1(J), the aggrieved party must file a formal Form LWC-WC-1008 (Disputed Claim for Compensation) with the local Workers' Compensation District Office within 15 calendar days of the determination's mailing date to secure an expedited trial before a Workers' Compensation Judge (WCJ).

Sources: Louisiana Revised Statutes (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: Louisiana Revised Statutes (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 Rule: The maximum allowable reimbursement (MAR) for a brand-name medication dispensed at a licensed retail storefront defaults to the pharmacy's documented Usual & Customary (U&C) charge or the carrier's pre-negotiated commercial PBM contract rate, whichever is lower.
• Generic Reimbursement Rule: Consistent with the brand-name baseline under Chapter 5, 1.06(2), generic medications filled at a brick-and-mortar retail storefront are billed and adjudicated based strictly on the storefront's Usual & Customary (U&C) public retail rate or the contracted network rate, avoiding arbitrary statutory wholesale markups.
• The $0.00 Statutory Dispensing Fee Restraint: Because Maine lacks a standalone, formulaic pharmacy fee schedule framework, there is no statutory or state-mandated professional dispensing fee applied to retail bills. Any professional handling fee or administrative surcharge must be factored directly into the pharmacy's baseline U&C retail rate; standalone handling fees appended to the medical bill will be programmatically denied by bill review systems.
• The "Lesser-Of" Network Adjudication Gate: Point-of-sale PBM routing engines and clearinghouse software must dynamically audit incoming retail transactions. The platform will automatically compress the final payment to the lowest calculation among: the submitted storefront U&C rate, the regional cash market average, or any pre-negotiated commercial PBM network network discount applied to the claim.

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: In strict alignment with Maine's core medical control framework under 39-A M.R.S.A. 206(1), the employer or their insurance carrier possesses the absolute statutory right to select a preferred provider, facility, or managed care pharmacy program for the first ten (10) days from the inception of healthcare services.
• In accordance with 39-A M.R.S.A. 206(2), once the initial 10-day window expires, the injured worker is granted the statutory right to select their own treating healthcare provider and choose any licensed retail pharmacy storefront to fill valid prescriptions, provided they notify the employer of their choice.

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

Pre-Authorization

• No: Open formulary design driven by strict generic substitution mandates and employer utilization networks.

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

OTC Restrictions

• The Written Prescription Imperative: Over-the-counter (OTC) medications supplied at a retail pharmacy storefront are completely non-reimbursable unless they are accompanied by a valid, signed written prescription or formal medical order from the authorized treating physician that establishes a direct therapeutic link to the accepted work-related injury.
• The Usual & Customary (U&C) Pricing Baseline: Validly prescribed OTC items dispensed at a retail counter do not follow a fixed regulatory markup grid or index. In strict accordance with Maine WCB Rules Chapter 5, 1.06(2), reimbursement defaults entirely to the lesser of the pharmacy's documented Usual & Customary (U&C) public retail rate or the insurance carrier's pre-negotiated commercial PBM network contract rate.
• The No-Handling-Fee Standard: Because OTC lines are processed under Maine's standard retail pricing rule where no standalone statutory dispensing fee framework exists, retail pharmacies cannot attach professional handling allowances or custom administrative surcharges to an OTC invoice. Any operational overhead must be natively captured within the storefront's standard U&C public retail rate.
• The Absolute Pre-Authorization Prohibition: Insurance carriers are statutorily prohibited from requiring prior authorization as a condition of payment for prescribed retail OTC items. Pharmacies are legally empowered to dispense the product to the injured worker at the counter up front.
• The Retroactive NOC Audit Gate: While an upfront authorization gate is illegal, the payer retains the full statutory right under 39-A M.R.S.A. 206 to retroactively audit and challenge the medical necessity of the prescribed OTC product. If the carrier elects to deny or cut down an OTC line item, it must pay all other undisputed items on the invoice and formally file a Form WCB-21 (Notice of Controversy) with the Board within 30 calendar days of receipt to preserve the dispute.

Sources: Maine Revised Statutes Annotated (M.R.S.A.) Title 39-A, 206; Maine Workers' Compensation Board (WCB) Rules and Regulations, Chapter 5, Section 1.05, Section 1.06, and Section 1.07

Topical Restrictions

• The Retail Topical Pricing Baseline: Standalone commercial topical medications (such as non-compounded prescription creams, transdermal ointments, gels, or patch kits) filled at a licensed retail pharmacy storefront do not follow an AWP-indexed percentage markup grid. The maximum allowable reimbursement defaults entirely to the lesser of the storefront's documented Usual & Customary (U&C) charge or the insurance carrier's pre-negotiated commercial PBM network contract rate.
• The Absolute Pre-Authorization Prohibition: Insurance carriers and self-insured employers are statutorily prohibited from requiring prior authorization or pre-certification as a condition of payment for prescribed retail topical lines. Storefront pharmacies are legally empowered to dispense any validly prescribed topical product to the injured worker at the counter up front without upfront carrier clearance.
• The Retroactive Reasonableness Audit Gate: While an upfront authorization gate cannot be legally enforced by a payer, the insurance carrier retains the absolute right under 39-A M.R.S.A. 206 to retroactively audit and challenge the medical necessity of the topical agent. The medication must directly align with the accepted injury's standard care path. If a retrospective review determines a high-cost topical patch or gel lacks documented clinical necessity, the line will be denied.
• The Repackager NDC Data Scrub: To eliminate arbitrary cost markups on specialized transdermal lines, automated bill review clearinghouses require the medical invoice to contain the item's original manufacturer National Drug Code (NDC). Bill review edits will programmatically strip away any secondary repackager or private-label store-brand NDCs, resetting the core verification check back to the primary source manufacturer.
• The Mandatory Notice of Controversy (NOC) Deadline: In accordance with WCB Rules Chapter 5, Section 1.07, if an insurance carrier elects to retroactively contest or deny a retail topical line item on the grounds of medical necessity, it cannot do so implicitly. The payer must immediately pay any undisputed portions of the bill and formally file a Form WCB-21 (Notice of Controversy) with the Board within 30 calendar days of receiving the invoice to legally preserve its right to a dispute.

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 1.05, Section 1.06, and Section 1.07

Compound Restrictions

• The Retail Compound Pricing Baseline: Multi-ingredient custom prescription compounds filled at a licensed retail storefront do not follow a dedicated regulatory markup or index-linked pricing sheet. The compound invoice defaults to the lesser of the retail pharmacy's documented Usual & Customary (U&C) charge for the completed prescription or the insurance carrier's pre-negotiated commercial PBM network contract rate.
• The No-Handling-Fee Standard: Because Maine administrative rules do not provide a formulaic pharmacy fee schedule or a standalone statutory dispensing fee framework for any pharmaceutical lines, retail storefronts cannot attach a separate professional compounding labor fee or an isolated handling allowance to the bill. All clinical assembly and overhead costs must be natively factored into the pharmacy's single, comprehensive retail U&C price.
• The Absolute Pre-Authorization Prohibition: Insurance carriers and self-insured employers are statutorily prohibited from requiring prior authorization as a condition of payment for medical services or prescribed medicines. A retail pharmacist is legally permitted to compound and dispense a custom medication immediately upon receipt of a valid provider script without seeking upfront payer approval.
• The Retroactive Reasonableness Audit Gate: While an upfront authorization gate cannot be legally enforced by a payer, the insurance carrier retains the absolute right under 39-A M.R.S.A. 206 to retroactively audit the medical necessity of the compound. Every active raw chemical and base ingredient within the compound must have an established therapeutic purpose that maps to the accepted industrial injury. If a retroactive clinical review determines the mix is experimental or inappropriate, the line will be denied.
• The Mandatory Notice of Controversy (NOC) Deadline: If an insurance carrier decides to retroactively challenge or deny a retail compound invoice on the grounds of medical necessity, it cannot do so implicitly or through quiet bill reductions. The payer must pay any undisputed portions of the bill and formally file a Form WCB-21 (Notice of Controversy) with the Board within 30 calendar days of receiving the invoice to legally preserve the dispute.

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 1.05, Section 1.06, and Section 1.07

Timelines

• Pharmacy Billing Submission Deadline: A licensed retail pharmacy storefront must submit its properly coded invoice to the employer or workers' compensation insurance carrier within 365 calendar days (1 year) from the exact date of dispensing. Late submissions are subject to a permanent, non-reimbursable administrative default.
• Payer Payment/Denial Window: The employer or workers' compensation insurance carrier has a mandatory processing window of exactly 30 calendar days from the receipt of a properly documented pharmacy invoice to either issue full payment or formally deny the line item.
• The Delayed-Notice Certified Mail Penalty Trigger: If an undisputed retail pharmacy bill remains unpaid past the initial 30-day window, the provider must send a formal notice of nonpayment via certified mail. If the carrier fails to issue payment within 30 days of receiving that certified letter, a statutory late penalty of $50.00 per day (capped at an absolute maximum of $1,500.00) accumulates on the overdue balance.
• The Retroactive Denial Dispute Gate (Notice of Controversy): Because Maine statutorily prohibits prospective prior authorizations, any challenge to a retail prescription occurs retroactively. Pursuant to WCB Rules Chapter 5, 1.07(5), if a carrier rejects or reduces a retail medication line on the grounds of medical necessity, the payer must pay all other undisputed items on the bill and formally file a Form WCB-21 (Notice of Controversy) with the Board within 30 calendar days of the bill's receipt to legally preserve the dispute.
• The Employee Hold-Harmless Provision: The injured worker is held completely harmless during any active billing dispute. Retail pharmacies are statutorily barred from balance billing or attempting to collect outstanding pharmaceutical or medical charges directly from the employee.
• The Formal Board Adjudication Request: If a billing dispute cannot be resolved through voluntary peer-to-peer discussion or mandatory Board-led mediation following the filing of a Form WCB-21, the aggrieved pharmacy or the carrier must file a formal Form WCB-100 (Petition for Award of Medical Benefits). This step secures a binding evidentiary hearing and final trial ruling before an Administrative Law Judge (ALJ).

Sources: Maine Revised Statutes Annotated (M.R.S.A.) Title 39-A, 205(4) & 206; Maine Workers' Compensation Board (WCB) Rules and Regulations, Chapter 5, Section 1.05, Section 1.06, and Section 1.07

Pricing Source

• Storefront's Documented Public Cash Price Ledger / PBM Internal Network Index

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

State Fee Schedule

Federal AWP Pricing Baseline
Retail pharmacy claims for injured workers covered under the Longshore and Harbor Workers' Compensation Act (LHWCA) are processed under the federal OWCP Medical Fee Schedule rather than state-specific pharmacy pricing rules.

Brand-Name Formula
Brand-name prescriptions are reimbursed at AWP × 0.90 + $4.00 dispensing fee.

Generic Formula
Generic prescriptions are reimbursed at AWP × 0.75 + $4.00 dispensing fee.

Dispensing Fee Cap
The professional dispensing fee is limited to $4.00 per prescription. Additional handling charges, regional adjustments, or processing surcharges cannot be added.

Lesser-of Pricing Rule
The final reimbursement is based on the lowest applicable amount among the federal OWCP formula, the pharmacy's Usual & Customary (U&C) charge, 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, Office of Workers' Compensation Programs (OWCP) Pharmacy Fee Schedule Framework.

Direct Care

Employee Pharmacy Choice
No. Injured maritime workers may use any licensed retail pharmacy to fill an authorized prescription. Employers cannot require an employee to use a specific mail-order pharmacy or restrict access to an independent local pharmacy.

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

Pre-Authorization

Routine Prescription Authorization
No centralized federal drug formulary is required under the LHWCA. Necessary prescriptions generally move through standard pharmacy benefit networks, which may apply utilization controls, generic substitution requirements, or limits on certain medications.

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

OTC Restrictions

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

Generic Pricing
When properly prescribed, OTC products are generally treated as generic items under the OWCP pharmacy pricing methodology at AWP × 0.75 + $4.00 dispensing fee.

Single Dispensing Fee
Only one $4.00 professional dispensing fee applies. Additional handling or service charges cannot be added to the pharmacy claim.

Retrospective Review
Routine OTC prescriptions may be dispensed without prospective authorization, but the carrier may 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 prescriptions are subject to the federal OWCP pricing methodology. Brand-name products are calculated at AWP × 0.90 + $4.00, while generic products use AWP × 0.75 + $4.00.

Repackager NDC Review
Claims may be reviewed against the original manufacturer's drug information to prevent inflated pricing associated with repackaged or private-label products.

Specialty Topicals
High-cost patches, gels, and other specialized topical products may require additional utilization review and documentation of medical necessity before reimbursement.

Refill Requirements
Continued topical treatment may require an updated prescription or clinical authorization to establish ongoing 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 Pricing
Compounded prescriptions are evaluated by individual ingredient. Brand ingredients are generally subject to the AWP × 0.90 calculation, while generic ingredients use AWP × 0.75.

Single Dispensing Fee
One $4.00 dispensing fee applies to the completed compound. Separate dispensing fees or additional compounding surcharges are not permitted.

NDC Requirements
Each ingredient should be submitted using the applicable original manufacturer or bulk supplier NDC. Missing or invalid ingredient information may result in rejection or reduced reimbursement.

Prior Authorization
Compounded medications may be subject to prospective authorization and medical-necessity review before dispensing.

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

Timelines

Pharmacy Billing Deadline
Pharmacies should submit properly coded claims within 365 days of dispensing under applicable federal OWCP requirements.

Payer Payment Window
Under 33 U.S.C. 914(b), applicable payment or dispute requirements generally operate within a 30-day period after receipt of the properly documented claim.

Late Payment Penalty
Under 33 U.S.C. 914(f), qualifying unpaid amounts may be subject to a 20% statutory penalty.

Notice of Dispute
When compensation is formally disputed, the payer may be required to submit a Form LS-207, Notice of Controversion of Right to Compensation, explaining the basis for the dispute.

Employee Protection
The injured worker is generally protected from being directly billed for compensable pharmacy charges.

Dispute Resolution
Unresolved disputes may proceed through an OWCP informal conference and, when necessary, to the Office of Administrative Law Judges (OALJ).

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

Pricing Source

Primary Pricing Reference
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-Name Reimbursement
Brand-name prescriptions are generally reimbursed at the lesser of the pharmacy's submitted Usual and Customary (U&C) charge or the applicable prevailing community rate.

Generic Reimbursement
Generic prescriptions are evaluated against prevailing local retail pricing and applicable PBM reimbursement standards.

Dispensing Fee
Maryland does not establish a dedicated statutory retail pharmacy dispensing fee under the provided fee-schedule framework. Pharmacy overhead and handling costs are generally incorporated into the applicable retail charge.

Lesser-of Pricing Rule
The final reimbursement may be limited to the lowest applicable amount among the pharmacy's U&C charge, prevailing regional retail pricing, and an applicable contracted PBM rate.

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

Direct Care

Employee Choice
No. Maryland law provides injured workers with the right to choose their treating medical providers. This also supports the ability to obtain authorized prescriptions through a licensed pharmacy of their choice.

Employers and carriers cannot require an injured employee to use a particular pharmacy network when doing so would conflict with applicable employee-choice requirements.

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

Pre-Authorization

Routine Prescription Authorization
No centralized Maryland workers' compensation drug formulary is identified under the provided framework. Individual carriers may still apply prospective or retrospective utilization review to prescription claims.

Source: Md. Code Ann., Lab. & Empl. § 9-660 / Maryland Workers' Compensation Commission.

OTC Restrictions

Prescription Requirement
OTC medications generally require a valid prescription or clinical order establishing their connection to the accepted workplace injury before reimbursement can be considered.

Reasonable Pricing Standard
Properly prescribed OTC products are not subject to a fixed AWP percentage under the provided Maryland framework. Reimbursement is instead based on a reasonable amount, including applicable retail or market pricing.

Compound Treatment
An OTC product billed as an individual item does not receive a separate professional dispensing fee. When incorporated into a prescription compound, the applicable professional compounding allowance may apply to the completed preparation.

Retrospective Review
Carriers may review OTC claims after dispensing. Items determined to be excessive or unrelated to the compensable injury may be denied.

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

Topical Restrictions

Community-Based Pricing
Commercial topical medications are generally reimbursed using the lesser of the pharmacy's U&C charge or the applicable prevailing community price rather than a fixed AWP percentage.

Repackager Review
Billing systems may review NDC information against the original manufacturer's data to prevent inflated reimbursement associated with repackaged products.

Specialty Topicals
High-cost topical medications, including specialized patches and gels, may be subject to utilization review and require supporting medical-necessity documentation.

Refill Controls
Continued topical treatment may require updated clinical documentation or a renewed prescription to confirm ongoing medical necessity.

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

Compound Restrictions

Ingredient-Level Billing
Compounded prescriptions should identify each active ingredient separately, including the applicable quantity and NDC information.

Ingredient Pricing
Individual compound ingredients are generally evaluated against the pharmacy's U&C pricing and applicable prevailing market rates rather than a fixed AWP percentage.

Professional Compounding Fee
A $10.00 professional compounding fee applies to the prescription rather than separate fees for each ingredient.

NDC Documentation
Original manufacturer or bulk supplier NDC information should be provided for each ingredient. Missing or invalid NDC information may result in claim edits or reduced reimbursement.

Prior Authorization
Compounded prescriptions may require prior authorization when the carrier's utilization review identifies the medication as a non-routine or high-cost treatment.

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; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide.

Timelines

Pharmacy Billing Deadline
Pharmacy invoices should generally be submitted within 12 months of the applicable dispensing date, claim acceptance, or determination of compensability. Exceptions may apply when good cause is established.

Payer Review Period
Carriers generally have 45 days after receiving a pharmacy bill to process payment or issue a formal denial under the provided Maryland reimbursement framework.

Late Payment Interest
Qualifying unpaid balances may accrue statutory interest at 10% per year after the applicable payment period.

Employee Protection
Injured workers are generally protected from direct balance billing for compensable workers' compensation pharmacy services.

Commission Disputes
A pharmacy disputing a payment decision may submit the appropriate medical-services claim and supporting billing documentation to the Maryland Workers' Compensation Commission (WCC) for review.

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

Pricing Source

Primary Pricing Reference
Regional prevailing retail and cash-market pricing serves as the primary reference for pharmacy reimbursement under the provided Maryland framework.

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

State Fee Schedule

• MassHealth-Based Pricing Structure: Massachusetts workers’ compensation pharmacy reimbursement follows the state’s MassHealth-based pricing methodology under 114.3 CMR 40.00.
• Brand-Name Drug Pricing: Brand medications are reimbursed at the lowest applicable amount among the Massachusetts Maximum Allowable Cost (MMAC), Actual Acquisition Cost (AAC), or the pharmacy’s Usual & Customary (U&C) charge, with a $10.02 dispensing fee added.
• Generic Drug Pricing: Generic medications are subject to the lowest applicable rate among the Federal Upper Limit (FUL), MMAC, AAC, or U&C pricing, plus the $10.02 professional dispensing allowance.
• Retail Dispensing Allowance: Licensed retail pharmacies receive a $10.02 professional dispensing fee for eligible prescriptions. This allowance does not apply in the same manner to routine medications dispensed from a physician’s office.

Sources: Massachusetts Executive Office of Health and Human Services (EOHHS) 101 CMR 331.00; 114.3 CMR 40.00; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Direct Care

• No: Massachusetts generally protects the injured employee’s right to choose medical care under M.G.L. Chapter 152, Section 30. Employers and carriers cannot arbitrarily require treatment from a specific physician, facility, or provider network.
• This provider-choice framework also supports pharmacy choice. An injured worker may obtain an authorized prescription from a licensed retail pharmacy, clinical pharmacy setting, or home-delivery service, subject to applicable workers’ compensation requirements.

Sources: Massachusetts General Laws (M.G.L.) Chapter 152, Section 30; 114.3 CMR 40.00

Pre-Authorization

• No: Massachusetts does not operate under a single closed statewide pharmacy formulary for routine prescriptions. Pharmacy reimbursement follows applicable fee schedule calculations, including separate treatment of brand and generic medications and generic substitution requirements.

Source: Mass. Gen. Laws ch. 152, Section 30; Massachusetts Department of Industrial Accidents Rules

OTC Restrictions

• Prescription Requirement: OTC medications are generally not reimbursable when purchased without an authorized prescription or clinical order connecting the medication to the accepted work injury.
• Applicable Pricing: When properly prescribed, an OTC medication is reimbursed under the applicable Massachusetts pharmacy pricing methodology. The allowable amount is determined using the lowest applicable FUL, MMAC, AAC, or U&C rate, together with the $10.02 dispensing allowance.
• Single OTC vs. Compound Use: An OTC product billed independently is treated as an individual pharmacy item. When an OTC ingredient becomes part of a pharmacist-prepared compound, the finished prescription is subject to Massachusetts compound billing requirements.
• Post-Payment Review: Routine OTC prescriptions generally do not require advance authorization. However, the carrier may subsequently review the medication for medical necessity and deny payment if the item is found unrelated to the compensable injury.

Sources: Massachusetts General Laws (M.G.L.) Chapter 152, Section 30; 114.3 CMR 40.00; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Topical Restrictions

• Standard Pricing Treatment: Commercial topical prescriptions, including creams, ointments, gels, transdermal products, and patches, are reimbursed using Massachusetts’ applicable brand or generic pricing methodology. Eligible retail claims also include the $10.02 dispensing allowance.
• Manufacturer NDC Verification: Pharmacy billing systems verify the product against the original manufacturer information. Repackager or secondary-distributor NDCs may be rejected when they do not support the underlying product valuation.
• Specialty Topical Review: High-cost patches and specialized topical medications may be subject to utilization review. Additional medical-necessity documentation may be required before payment is authorized.
• Refill Monitoring: Continued topical therapy may be reviewed for appropriate utilization. Additional refills may require updated clinical documentation demonstrating that treatment remains medically necessary.

Sources: Massachusetts 114.3 CMR 40.00; 452 CMR 6.00; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must identify the individual ingredients used in the preparation, including the applicable quantities and NDC information.
• Ingredient Pricing: Each ingredient is evaluated under the applicable Massachusetts pricing hierarchy, using the lowest eligible FUL, MMAC, AAC, or U&C amount. Invalid or unusable NDC information can result in rejection of the affected ingredient.
• One Dispensing Fee: A completed compound is eligible for one $10.02 professional dispensing fee. Pharmacies cannot add separate dispensing charges for each ingredient or impose additional compounding labor fees outside the applicable rules.
• Original NDC Requirement: Ingredient billing should identify the original manufacturer or qualifying bulk supplier. Missing or invalid NDC information can prevent reimbursement for the affected component.
• Utilization Review: Custom compounds may receive additional utilization review because of their specialized nature and potential cost. Carrier authorization may be required before the compound is reimbursed.

Sources: Massachusetts 114.3 CMR 40.00; 452 CMR 6.00; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Timelines

• Pharmacy Submission Deadline: Pharmacy bills must be submitted within the applicable 90-day period following dispensing under Massachusetts workers’ compensation billing requirements. Claims submitted after the applicable deadline may be denied.
• Payer Review Period: The employer or workers’ compensation carrier generally has 45 days after receiving a properly documented bill to process payment or issue a denial.
• Late Payment Interest: Unpaid, undisputed amounts may accrue statutory interest at 12% annually after the applicable payment period.
• No Balance Billing: Injured employees are protected from being personally charged for covered workers’ compensation pharmacy expenses during a payment dispute.
• DIA Dispute Process: When a pharmacy cannot resolve a payment dispute directly with the carrier, the matter may proceed through the Massachusetts Department of Industrial Accidents (DIA), including the applicable third-party claim and hearing process.

Sources: Massachusetts General Laws (M.G.L.) Chapter 152, Sections 13 & 30; 452 CMR 6.00

Pricing Source

• MassHealth Drug Pricing References: Massachusetts pharmacy reimbursement relies on MassHealth pricing resources, including MMAC, AAC, and FUL benchmarks.

Sources: Massachusetts General Laws (M.G.L.) Chapter 152, Section 13; 114.3 CMR 40.00; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

State Fee Schedule

• AWP-Based Reimbursement: Michigan uses an Average Wholesale Price (AWP) methodology for qualifying prescription drugs dispensed through retail pharmacies. Pricing information may be validated against recognized databases such as Red Book or Medi-Span.
• Brand-Name Formula: Single-source brand medications are reimbursed at AWP multiplied by 0.90, plus a $3.50 dispensing fee.
• Generic Formula: Multi-source generic medications are reimbursed at AWP multiplied by 0.90, plus a $5.50 dispensing fee.
• Lesser-of Pricing: The applicable fee schedule amount is compared with the pharmacy’s Usual & Customary (U&C) charge. Reimbursement is limited to the lower eligible amount.
• NDC Validation: Billing systems use the original manufacturer NDC to establish the appropriate drug pricing. Repackaged or secondary NDCs may be adjusted back to the underlying manufacturer product.

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

Direct Care

• Yes: Michigan permits employer or carrier direction of medical care during the first 28 days after a workplace injury under MCL 418.315.
• After that initial period, the injured employee may select a different treating physician by providing the required notice and provider information to the carrier.

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

Pre-Authorization

• No: Routine pharmacy reimbursement is governed by Michigan’s fee schedule and utilization requirements rather than a general statewide prescription pre-authorization requirement. Brand and generic substitution rules may apply.

Source: Mich. Comp. Laws 418.315; Michigan Workers' Disability Compensation Agency Rules

OTC Restrictions

• Prescription Requirement: OTC products require an authorized prescription or clinical order connecting the medication to the compensable workplace injury before reimbursement is available.
• Quantity: Properly prescribed OTC medications may be dispensed according to the physician’s authorized treatment instructions, including standard supply quantities.
• Pricing: Eligible OTC medications are processed under Michigan’s pharmacy pricing methodology. As generic products, qualifying OTC lines are subject to the applicable AWP-based calculation and $5.50 dispensing allowance.
• Retrospective Review: Routine OTC prescriptions generally do not require advance authorization. Carriers may later examine the medication for medical necessity and deny unrelated or excessive charges.

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

Topical Restrictions

• 30-Day Supply Limit: Commercial topical medications dispensed through retail pharmacies are generally limited to a 30-day supply per transaction under Michigan’s applicable pharmacy rules.
• Acquisition-Cost Basis: Reimbursement for qualifying topical medications is based on documented acquisition cost plus the applicable dispensing allowance rather than the standard AWP calculation.
• $8.50 Dispensing Allowance: Eligible topical prescriptions may receive an $8.50 dispensing fee, subject to the applicable frequency restrictions.
• NDC Verification: Billing systems verify topical products against manufacturer information and may remove repackager-based pricing when it does not represent the original product.

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

Compound Restrictions

• Separate Ingredient Reporting: Compounded prescriptions must identify each active ingredient and raw material separately, including quantity and applicable NDC information.
• Compound Pricing: Individual ingredients are generally evaluated using the applicable AWP-based calculation. Reimbursement for a custom compound is subject to a $600 maximum.
• Single Compounding Fee: Michigan permits one $10.00 compounding fee per completed prescription. Separate fees cannot be added for individual ingredients.
• Manufacturer NDC Requirement: Ingredient-level billing should use the applicable original manufacturer or bulk supplier NDC. Repackager codes may result in pricing adjustments.
• Authorization Review: Custom compounds may be subject to utilization controls and require carrier approval before dispensing or reimbursement.

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

Timelines

• Submission Deadline: Retail pharmacy bills should be submitted within one year of the dispensing date. Claims submitted after the applicable deadline may be administratively rejected.
• Payer Processing Period: Carriers generally have 30 days after receiving a properly documented bill to pay or formally dispute the charge.
• Late Interest: Unpaid, undisputed amounts may accrue interest at 12% annually after the applicable payment deadline.
• Employee Protection: Injured workers are not responsible for covered pharmacy charges that remain disputed between the pharmacy and workers’ compensation payer.
• Medical Dispute Process: Unresolved pharmacy reimbursement disputes may be brought before the Michigan Workers' Disability Compensation Agency through the applicable medical dispute process.

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

Pricing Source

• AWP and Acquisition Data: Michigan pharmacy reimbursement relies on Red Book and Medi-Span AWP data together with applicable manufacturer acquisition-cost information.

Sources: Michigan Compiled Laws (MCL) 418.315; Mich. Admin. Code R. 418.101003a; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

State Fee Schedule

• Electronic Claim Pricing: Electronic pharmacy claims are reimbursed at the lowest applicable amount among AWP multiplied by 0.88 plus a $3.65 dispensing fee, the state Medicaid MAC amount plus $3.65, or the pharmacy’s U&C charge.
• Paper Claim Pricing: Paper claims follow a separate calculation. The allowable amount is the lower of 100% of AWP plus a $5.14 dispensing fee or the pharmacy’s U&C charge.
• Transaction-Based Fees: Electronic submissions receive the $3.65 dispensing allowance, while qualifying paper submissions use the $5.14 amount.
• Lesser-of Review: Pharmacy claims are automatically compared against the applicable state formula, U&C pricing, and network reimbursement terms, with payment limited to the lowest allowable amount.

Sources: Minnesota Rules Part 5221.4070, Subparts 3 & 4; Minnesota Statutes 176.136; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Direct Care

• Yes: Minnesota permits employers and carriers to direct pharmacy care through an approved pharmacy or network under applicable workers’ compensation rules.
• 15-Mile Exception: The direction requirement may not apply when the designated pharmacy is located more than 15 miles from the employee’s residence. In that situation, the employee may use another available pharmacy.
• Managed Care: Employees enrolled in an approved managed care arrangement may also be required to obtain pharmacy services through the designated network, subject to applicable exceptions.

Sources: Minnesota Statutes 176.135, Subdivisions 1(f), (g), & (h); Minnesota Statutes 176.1351; Minnesota Rules Part 5221.4070

Pre-Authorization

• No: Minnesota does not require universal prospective authorization for routine prescriptions. Reimbursement varies according to whether the claim is submitted electronically or manually, with electronic claims generally using the AWP x 0.88 plus $3.65 methodology.

Source: Minn. Stat. 176.136; Minnesota Department of Labor and Industry Pharmacy Rules

OTC Restrictions

• Prescription Requirement: OTC medications require a valid prescription or clinical order establishing their relationship to the compensable injury before reimbursement can be considered.
• Electronic Pricing: Electronic OTC claims are subject to the lower of AWP x 0.88 plus $3.65 or the applicable Medicaid MAC amount plus $3.65.
• Paper Pricing: Manually submitted claims use a different calculation, allowing the lower of 100% of AWP plus $5.14 or the pharmacy’s U&C charge.
• Procedure Codes: OTC medications do not generally require the same procedure-code treatment used for legend drugs.
• Post-Payment Review: Carriers may review OTC claims after dispensing and deny reimbursement where the medication is excessive or unrelated to the work injury.

Sources: Minnesota Rules Part 5221.4070, Subparts 2, 3 & 4; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Topical Restrictions

• Electronic vs. Paper Pricing: Commercial topical prescriptions follow Minnesota’s submission-based pricing structure. Electronic claims use the AWP x 0.88, MAC, or U&C methodology, while paper claims use the 100% AWP plus $5.14 or U&C calculation.
• Manufacturer Verification: Topical products are reviewed against manufacturer pricing information, with repackager NDCs subject to adjustment when necessary.
• Specialty Topical Review: Expensive topical products, patches, and specialty gels may be flagged for utilization review and require documentation supporting medical necessity.
• Refill Controls: Continued topical treatment may be subject to utilization review, particularly when repeated refills require confirmation of ongoing medical necessity.

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

Compound Restrictions

• Ingredient-Level Billing: Each component of a compound must be separately identified, including the quantity and applicable NDC.
• Electronic Compound Pricing: Electronic compound claims apply the lower of AWP x 0.88 plus $3.65, the applicable Medicaid MAC amount plus $3.65, or U&C pricing to the eligible components.
• Paper Compound Pricing: Paper submissions use the lower of 100% of AWP plus $5.14 or the pharmacy’s U&C amount.
• One Dispensing Fee: Only one applicable dispensing allowance applies to the completed compound. Pharmacies cannot add a separate fee for each ingredient or an additional compounding surcharge.
• NDC Documentation: Original manufacturer or qualifying bulk-supplier NDCs should be reported for each ingredient. Invalid or missing NDC information may result in rejection of the affected component.
• Utilization Review: Custom compounds may require additional carrier review or authorization before reimbursement.

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

Timelines

• Billing Deadline: Pharmacy claims should be submitted within one year of the dispensing date under applicable Minnesota workers’ compensation billing rules.
• Payer Response Period: Employers and carriers generally have 30 days after receiving a properly documented bill to pay or dispute the charge.
• Interest on Late Payment: Unpaid eligible amounts may accrue statutory interest under Minnesota law after the applicable payment period.
• No Employee Balance Billing: Workers should not be personally billed for covered pharmacy expenses while reimbursement remains under workers’ compensation review.
• DLI Dispute Process: Unresolved reimbursement disputes may be submitted to the Minnesota Department of Labor and Industry through the applicable Medical Request process for administrative review or hearing.

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

Pricing Source

• AWP and State Pricing References: Minnesota pharmacy reimbursement uses recognized AWP databases, including Red Book and Medi-Span, together with applicable Minnesota Department of Human Services pricing references.

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

State Fee Schedule

• AWP-Based Methodology: Mississippi establishes retail prescription reimbursement using Average Wholesale Price as the primary pricing benchmark.
• Brand Medications: Single-source brand prescriptions are reimbursed at AWP plus a $5.00 professional dispensing fee.
• Generic Medications: Multi-source generic prescriptions are reimbursed at 95% of AWP plus the $5.00 dispensing allowance.
• Lesser-of Requirement: Where no separate network agreement controls, payment is limited to the lower of the pharmacy’s billed amount or the applicable fee schedule allowance.
• Original Product Identification: Repackaged and physician-dispensed products are evaluated using the original labeler NDC. The retail dispensing fee does not apply to physician-dispensed medications.

Sources: Mississippi Workers' Compensation Commission Medical Fee Schedule Manual; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Direct Care

• No: Mississippi generally permits the injured employee to select their treating physician and an appropriate specialist or referral provider.
• The same provider-choice framework extends to pharmacy services. Employers and carriers cannot require an employee to obtain prescriptions exclusively through a designated pharmacy or mail-order program.

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

Pre-Authorization

• No: Mississippi’s pharmacy rules do not impose a universal pre-authorization requirement for routine prescriptions. The state’s updated fee schedule incorporates revised generic pricing and reimbursement calculations effective June 1, 2026.

Source: Miss. Code Ann. 71-3-15; Mississippi Workers' Compensation Commission 2026 Fee Schedule

OTC Restrictions

• Prescription Requirement: OTC products require an authorized prescription or clinical order connecting the medication to the accepted work injury.
• Generic Pricing: Eligible OTC medications are treated under the generic pharmacy pricing methodology, using 95% of AWP plus the $5.00 dispensing allowance.
• Compound Treatment: An OTC product billed independently is subject to the standard retail allowance. When the OTC ingredient becomes part of a compound, the completed prescription is reviewed under Mississippi’s compound requirements.
• Retrospective Review: Routine OTC medications may generally be dispensed without advance authorization, but the carrier can later review the claim and deny items that are excessive or unrelated to the compensable injury.

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

Topical Restrictions

• Commercial Topical Pricing: Prescription creams, ointments, gels, patches, and other commercial topical products follow Mississippi’s standard brand or generic reimbursement formulas.
• OTC Topical Caps: Certain OTC topical products have separate reimbursement limits. Creams and lotions are capped at $30 for a 30-day supply, while topical patches are capped at $75 for a 30-day supply, subject to prorating.
• NDC Review: Pharmacy billing systems validate topical products against original manufacturer information and may remove pricing associated with secondary repackagers.
• Specialty Products: High-cost patches and specialized topical medications may trigger utilization review and require supporting medical-necessity documentation.

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

Compound Restrictions

• Detailed Ingredient Billing: Compounds must be reported by individual ingredient, including the quantity and corresponding NDC information.
• Ingredient Pricing: Brand components are evaluated at AWP, while generic components use 95% of AWP. Missing or invalid NDC information may result in the affected ingredient receiving no reimbursement.
• Single Dispensing Fee: A completed compound receives one $5.00 professional dispensing fee. Separate fees cannot be added for individual ingredients or additional compounding labor.
• Topical Compound Limit: Prescription topical compounds are subject to a maximum reimbursement of $200 for a 30-day supply, prorated where applicable, or the lower amount produced by the standard fee schedule.
• Authorization Review: Custom compounds may be subject to prospective utilization controls and require carrier authorization before reimbursement.

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

Timelines

• Submission Deadline: Retail pharmacy bills should be submitted within 180 days of dispensing. Late submissions may be denied unless an applicable exception is established.
• Payer Processing Period: Employers and carriers generally have 30 days after receiving a properly documented bill to pay or dispute the charge.
• Late-Payment Interest: Eligible unpaid amounts may accrue interest at 10% annually after the applicable 30-day payment period.
• Employee Protection: Injured workers are protected from direct collection attempts for covered pharmacy charges involved in a workers’ compensation billing dispute.
• MWCC Dispute Process: Unresolved pharmacy reimbursement disputes may proceed through the Mississippi Workers' Compensation Commission using the applicable medical dispute resolution process.

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

Pricing Source

• AWP Pricing Database: Mississippi pharmacy reimbursement relies on recognized AWP sources such as Red Book and Medi-Span.

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

State Fee Schedule

• No Dedicated Pharmacy Formula: Missouri does not establish a separate formulaic workers’ compensation pharmacy fee schedule for retail prescription medications.
• Brand Pricing: Brand-name medications are generally evaluated using the pharmacy’s Usual & Customary (U&C) retail charge.
• Generic Pricing: Generic medications are likewise based on the pharmacy’s U&C amount rather than a prescribed percentage reduction from AWP.
• Fair and Reasonable Standard: Although Missouri does not establish a fixed pharmacy pricing formula, submitted charges must remain fair and reasonable. Payer review systems may compare pharmacy charges with prevailing community rates.
• Physician-Dispensed Products: Missouri does not provide a separate state pharmacy formula specifically governing physician-dispensed or repackaged medications.

Sources: Missouri Revised Statutes 287.140; Missouri Code of State Regulations 8 CSR 50-2.030; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Direct Care

• Yes: Missouri allows the employer or workers’ compensation carrier to direct medical treatment under the state’s workers’ compensation system.
• This direction may include the selection of treating physicians, specialists, medical facilities, and pharmacy providers. The employee generally does not have an independent right to establish a separate pharmacy pathway at the employer’s expense.

Sources: Missouri Revised Statutes 287.140.1; Missouri Division of Workers' Compensation Employer Liability Guidelines

Pre-Authorization

• No: Missouri does not operate under a universal pharmacy pre-authorization requirement. Routine prescriptions are generally managed through carrier pharmacy networks, utilization review, and generic substitution requirements.

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

OTC Restrictions

• Prescription Requirement: An OTC medication must have an authorized prescription or clinical order connecting it to the accepted workplace injury before reimbursement is available.
• U&C Pricing: Properly prescribed OTC medications are reimbursed using the pharmacy’s U&C charge, subject to review against reasonable and prevailing community pricing.
• Dispensing Fee: Missouri does not establish a separate statutory dispensing fee for routine OTC pharmacy transactions. The allowable amount is therefore based on the underlying U&C pricing framework.
• Post-Payment Review: Routine OTC products generally do not require advance authorization. The carrier may subsequently review the medication and deny reimbursement when the product is unnecessary, excessive, or unrelated to the work injury.

Sources: Missouri Revised Statutes 287.140; Missouri Code of State Regulations 8 CSR 50-2.030; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Topical Restrictions

• No Dedicated Topical Formula: Missouri does not establish a separate state reimbursement formula or specific quantity cap exclusively for commercial topical medications.
• U&C Reimbursement: Prescription creams, ointments, gels, transdermal products, and patches are generally reimbursed using the pharmacy’s U&C charge, subject to the state’s fair-and-reasonable standard.
• NDC Validation: Pharmacy review systems may verify topical products against original manufacturer information and adjust repackager-based pricing when appropriate.
• Specialty Topical Review: Higher-cost topical products may receive utilization review. Supporting documentation may be required when a product exceeds standard utilization expectations.

Sources: Missouri Revised Statutes 287.140; Missouri Code of State Regulations 8 CSR 50-2.030; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Compound Restrictions

• Ingredient Reporting: Each component of a compounded prescription should be separately identified, including its quantity and NDC information.
• U&C Ingredient Pricing: Missouri does not establish a dedicated compound pricing grid. Ingredients are instead evaluated under the pharmacy’s U&C framework, subject to reasonable and prevailing market pricing.
• No Formulaic Compounding Fee: Missouri does not provide a standard workers’ compensation compounding fee schedule. Additional handling or laboratory charges must therefore remain consistent with applicable reimbursement requirements.
• NDC Requirements: Missing, invalid, or unusable ingredient NDCs may result in the affected component being rejected during bill review.
• Authorization Review: Custom compounds may receive additional utilization review because of their complexity and cost. Carrier authorization may be required before reimbursement.

Sources: Missouri Revised Statutes 287.140; Missouri Code of State Regulations 8 CSR 50-2.030; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Timelines

• Billing Submission: Retail pharmacy claims should generally be submitted within one year of the dispensing date. Late submissions may be subject to additional administrative review or denial.
• Payer Review Period: Employers and workers’ compensation carriers generally have 30 days after receiving a properly documented pharmacy bill to process or dispute the charge.
• Employee Protection: Injured employees are protected from being directly billed for covered workers’ compensation pharmacy services during a reimbursement dispute.
• Formal Dispute Process: Pharmacies disputing reimbursement may pursue the applicable Missouri Division of Workers' Compensation process, including the required request and application procedures for medical fee disputes.

Sources: Missouri Revised Statutes 287.140.13; Missouri Code of State Regulations 8 CSR 50-2.030

Pricing Source

• Retail U&C Market Data: Missouri pharmacy reimbursement is primarily based on pharmacy Usual & Customary pricing and regional retail market benchmarks.

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

State Fee Schedule

• AWP-Based Pricing Structure: Montana sets reimbursement for outpatient prescription drugs dispensed by licensed retail pharmacies using Average Wholesale Price (AWP) benchmarks.
• Brand-Name Drug Rate: Single-source brand medications are reimbursed at a maximum of AWP × 0.90 + $3.00 dispensing fee.
• Generic Drug Rate: Multi-source generic medications are subject to a lower maximum of AWP × 0.75 + $3.00 dispensing fee.
• Lesser-of Payment Rule: 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 Exceptions: Montana permits physician dispensing only in specified statutory circumstances and does not establish separate pricing guidance 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. Employers and insurers cannot require the worker to use a particular provider for the initial treatment.
• MCO/PPO Exception: Under MCA 39-71-315, an employer or insurer participating in an approved Managed Care Organization (MCO) or Preferred Provider Organization (PPO) may select a different primary treating physician after the initial visit.

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

Pre-Authorization

• Yes: Montana follows the closed ODG Drug Formulary. Medications designated as non-preferred or "N" status generally require prospective authorization from the payer.

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

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable through a retail pharmacy unless supported by a valid written prescription or clinical order from the authorized treating physician connecting the medication to the accepted work injury.
• Generic Pricing Method: When properly prescribed, OTC medications are processed under the generic reimbursement formula of AWP × 0.75 + $3.00 dispensing fee.
• Single Item vs. Compound: A standalone OTC medication receives one $3.00 dispensing fee. If 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 may later review medical necessity. Items determined to be excessive or unrelated to the injury may be denied.

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

Topical Restrictions

• Standard Topical Pricing: Commercial topical prescriptions dispensed at retail are priced under Montana's standard formulas. Brand products use AWP × 0.90 + $3.00, while generic products use AWP × 0.75 + $3.00.
• NDC Verification: Bill review systems verify topical products against the original manufacturer's NDC and remove pricing associated with secondary repackager NDCs.
• Specialty Topical Review: Expensive transdermal products and specialized anti-inflammatory gels may trigger utilization review. Documentation supporting medical necessity may be required before payment is approved.
• Refill Monitoring: Continued topical refills may be reviewed for medical necessity, with additional documentation required when utilization exceeds established guidelines.

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

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must be itemized by individual ingredient, including the applicable metric quantity and NDC for each component.
• Ingredient Pricing: Brand ingredients are limited to AWP × 0.90, while generic ingredients are limited to AWP × 0.75. Missing, invalid, or dummy NDCs may result in the ingredient being assigned a $0.00 value during bill review.
• One Dispensing Fee: The completed compound is eligible for one $3.00 dispensing fee. Separate handling fees or additional compounding labor surcharges cannot be stacked onto individual ingredients.
• Original Manufacturer NDC: Each ingredient must be reported using the NDC associated with the original manufacturer or bulk supplier. Repackager NDCs may be rejected during automated review.
• Authorization Requirement: Due to the cost and utilization concerns associated with compounded medications, retail compounds may be subject to point-of-sale authorization requirements before payment is approved.

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

Timelines

• Billing Submission Deadline: Retail pharmacies must submit properly coded bills within 365 calendar days of dispensing. Late submissions may be administratively denied.
• Payer Review Period: Employers and workers' compensation insurers have 30 calendar days after receiving a properly documented bill to pay or deny the charge.
• Employee Protection: Injured employees are protected from balance billing while a pharmacy claim is under dispute. Pharmacies and billing entities cannot pursue the disputed balance directly from the worker.
• DLI Dispute Process: Unresolved payment disputes may be submitted through a Medical Dispute Petition to the Montana Department of Labor and Industry (DLI), with mediation available before further proceedings in the Workers' Compensation Court.

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 use a preset percentage-based pharmacy fee schedule for workers' compensation prescriptions.
• Brand-Name Pricing: Single-source brand medications are generally reimbursed based on the pharmacy's actual billed charge or another reasonable rate.
• Generic Pricing: Multi-source generic medications are likewise evaluated using the pharmacy's actual charge or reasonable cost basis rather than a fixed pricing formula.
• Reasonableness Review: A billed prescription may be paid at the actual charge unless the payer can demonstrate that the amount exceeds the customary charge for comparable services in the local community.
• Physician Dispensing: Nebraska does not establish separate physician-dispensing or repackaged-drug guidance within these retail pharmacy provisions.

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 and establish the applicable care network under Neb. Rev. Stat. 48-120(2).
• Existing Physician Exception: An injured worker may choose a physician with whom they had an established treatment relationship before the injury, provided the required notice is given to the employer.

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

Pre-Authorization

• No: Nebraska follows an open formulary approach, with carrier and PBM utilization controls used to monitor areas such as opioid duration and generic medication selection.

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

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless a valid written prescription or clinical order establishes their connection to the accepted workplace injury.
• Actual Charge Review: Properly prescribed OTC products are reimbursed according to the pharmacy's actual charge, subject to review against the regular charge for comparable cases in the community.
• No Separate Dispensing Fee: Nebraska does not establish a specific workers' compensation dispensing fee for these OTC transactions.
• Retrospective Review: Routine OTC prescriptions may be dispensed without prospective authorization, but carriers may later review the charge and medical necessity. Excessive or unrelated items may be denied.

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

Topical Restrictions

• Actual Charge Pricing: Commercial topical prescriptions are reimbursed according to the pharmacy's submitted actual charge, subject to Nebraska's reasonable-charge review. This applies to both brand and generic topical products.
• NDC Validation: Automated review systems verify topical medications against manufacturer information and may remove pricing associated with repackager NDCs.
• Specialty Topical Review: High-cost transdermal products and specialized topical medications may undergo utilization review when their cost or use exceeds established guidelines.
• Refill Monitoring: Repeated topical prescriptions may require updated clinical documentation confirming continued medical necessity.

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

Compound Restrictions

• Itemized Ingredients: Compounded prescriptions must be billed by individual ingredient, with each component identified by quantity and applicable NDC.
• Reasonable Charge Standard: Compound ingredients are evaluated against the pharmacy's actual charge and Nebraska's regular-charge reasonability standards. Missing or invalid NDC information may result in a $0.00 line value during automated review.
• No Stacked Fees: Nebraska does not provide a formulaic workers' compensation compounding fee structure, so pharmacies cannot add multiple handling charges or separate laboratory premiums.
• Authorization Review: Compounded medications may be subject to prospective authorization because of their non-routine nature and potential cost concerns.

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

Timelines

• Billing Submission Deadline: Properly coded pharmacy bills should be submitted within 365 calendar days of dispensing. Late claims may face administrative review or denial.
• Payer Review Period: Under Neb. Rev. Stat. 48-125, the employer or carrier has 30 calendar days after receiving a properly documented bill to pay or deny the charge.
• Late-Payment Interest: Unpaid, undisputed charges may accrue 14% annual interest after the applicable payment period, beginning on the 31st day.
• Employee Protection: Injured workers are protected from balance billing while pharmacy charges remain under dispute.
• Court Dispute Process: Unresolved pharmacy payment disputes may be brought before the Nebraska Workers' Compensation Court for formal adjudication.

Sources: Nebraska Revised Statutes (Neb. Rev. Stat.) 48-120 & 48-125; Nebraska Workers' Compensation Court Rules of Procedure

Pricing Source

• Pharmacy Actual Billed Ledger 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 Reimbursement: Nevada regulates outpatient prescription reimbursement through the Nevada Medical Fee Schedule (NMFS), using the Average Wholesale Price (AWP) applicable on the dispensing date.
• Retail Brand and Generic Rate: Both brand-name and generic medications are subject to AWP + $13.70 professional dispensing fee when dispensed through a retail pharmacy.
• Lesser-of Requirement: Final payment is limited to the lowest applicable amount among the state fee schedule, the pharmacy's U&C charge, or an agreed contractual rate.
• Inpatient Drug Treatment: Medications provided during an inpatient hospital stay are not separately reimbursed through the retail pharmacy schedule. Those costs are incorporated into the hospital's applicable per diem reimbursement.

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

Direct Care

• Yes: Nevada permits employer or carrier-directed care when the claim operates through an approved Organization for Managed Care (MCO) or Preferred Provider Organization (PPO).
• Open-Claim Pharmacy Choice: When the claim is not subject to a directed care arrangement, the injured employee may use a licensed retail pharmacy that participates in the carrier's designated PBM network.

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

Pre-Authorization

• No: Nevada generally follows an open formulary structure with PBM utilization controls. Generic substitution is required for multi-source medications at the point of sale.

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

OTC Restrictions

• Prescription Requirement: OTC and nonprescription medications are not reimbursable unless supported by a valid prescription or clinical order connecting the medication to the accepted workplace injury.
• Lesser-of Pricing: Properly prescribed OTC products are subject to the lower of AWP + $13.70, the pharmacy's U&C charge, or the applicable contracted PBM rate.
• Additional Fee Limits: Retail pharmacies cannot add separate compounding or custom handling charges to an OTC transaction unless expressly permitted by the applicable fee schedule.
• Inpatient Exception: OTC medications used during an inpatient hospital stay are included within the hospital's global per diem payment rather than separately reimbursed.

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

Topical Restrictions

• Standard Topical Pricing: Commercial topical medications are reimbursed using the applicable AWP-based fee schedule amount or the pharmacy's U&C charge, whichever is lower.
• NDC Verification: Repackaged topical products are reviewed against the original manufacturer's NDC to establish the applicable AWP pricing baseline.
• Prior Authorization Review: High-cost topical products, including specialty patches and anti-inflammatory gels, may require prospective authorization when they reach applicable financial or utilization thresholds.
• Refill Controls: Continued topical use may be subject to utilization review and updated documentation supporting ongoing medical necessity.

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

Compound Restrictions

• Ingredient-Level Billing: Each component of a compounded prescription must be separately identified, including quantity and the applicable NDC.
• AWP Ingredient Limit: Compound ingredients are generally limited to 100% of the manufacturer's AWP. Missing, invalid, or dummy NDCs may result in a $0.00 value during automated review.
• Topical Compound Cap: Under the February 1, 2026 fee schedule revisions, customized topical compounds are limited to the lesser of $240 for a 30-day supply, prorated as appropriate, or the amount otherwise payable under the standard compound fee schedule.
• Authorization Requirement: Custom compounds may be stopped at the point of sale until the required carrier authorization is obtained.

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

Timelines

• Billing Submission Deadline: Retail pharmacy bills should be submitted within 90 calendar days of dispensing. Late submissions may be subject to administrative review or denial.
• Payer Review Period: Under NRS 616C.136, employers, third-party administrators, and carriers have 30 calendar days after receiving a properly documented bill to pay or deny the charge.
• Late-Payment Interest: Undisputed balances remaining unpaid after the 30-day period may accrue statutory interest under NRS 616C.136.
• Employee Protection: Under NRS 616C.135, pharmacies and billing entities cannot pursue disputed workers' compensation pharmacy charges directly from the injured employee. Violations may result in an administrative penalty of up to $250 per occurrence.
• DIR Dispute Process: Unresolved medical fee disputes may be submitted to the Workers' Compensation Section of the Nevada Division of Industrial Relations through a Request for Resolution of a Medical Fee Dispute.

Sources: Nevada Revised Statutes (NRS) 616C.135 & 616C.136; Nevada Administrative Code (NAC) Chapter 616C; Division of Industrial Relations Workers' Compensation Section

Pricing Source

• Red Book / Medi-Span AWP Master Database

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

State Fee Schedule

• No Mandated Pharmacy Fee Schedule: New Hampshire does not use a preset or formulaic percentage-based pharmacy fee schedule for workers' compensation prescriptions.
• Brand-Name Retail Pricing: Reimbursement for single-source brand-name medications is based on the pharmacy's reasonable rate.
• Generic Retail Pricing: Reimbursement for multi-source generic medications is based on reasonable value rather than a fixed pricing formula.
• Reasonable Value Standard: Workers' compensation pharmacy reimbursement is based on the reasonable value of the services or care provided rather than a state-mandated pharmacy fee schedule.
• Provider Burden of Proof: Under RSA 281-A:24, I(b), the healthcare provider or retail pharmacy must establish that its submitted charges are reasonable if challenged by the payer.
• Physician Dispensing: New Hampshire does not provide specific guidance for physician-dispensed or repackaged drugs within this pricing framework.

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

Direct Care

• No: Under RSA 281-A:23, VII, an injured employee has the right to select their own pharmacy or pharmacist for medications required under workers' compensation. This provides the employee with freedom to choose the pharmacy used to fill prescriptions.

Sources: New Hampshire Revised Statutes Annotated (RSA) 281-A:23, Subdivisions I and VII, and 281-A:23-a; Workers' Comp Fact Sheet; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Pre-Authorization

• No: New Hampshire does not use a state-mandated pharmacy fee schedule for workers' compensation claims. Reimbursement is generally based on the reasonable value of the services or medication provided.

Source: RSA Chapter 281-A / New Hampshire Department of Labor

OTC Restrictions

• Prescription Requirement: OTC or non-legend medications are not reimbursable unless accompanied by a valid signed prescription or clinical order from the authorized treating physician establishing a connection to the accepted workplace injury.
• Generic Substitution: Under RSA 281-A:23, I, generic substitution requirements apply to both legend and non-legend medications unless the practitioner specifically indicates that the medication is medically necessary.
• Reasonable Value Pricing: Prescribed OTC medications are reimbursed based on reasonable value rather than an unrestricted retail price or AWP-based formula. Charges may be adjusted to a fair-market community rate when an audit identifies excessive pricing.
• Retroactive Medical Necessity Review: Routine OTC medications do not require prospective authorization. However, the payer may conduct a retrospective review and deny reimbursement if the medication is excessive or unrelated to the accepted workplace injury.

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

Topical Restrictions

• Reasonable Value Pricing: Standalone commercial topical medications, including prescription creams, ointments, gels, and transdermal products, are reimbursed based on reasonable value and remain subject to regional market review.
• Repackager NDC Review: Bill review systems may review NDC information and remove secondary repackager identifiers when necessary to verify the manufacturer's underlying pricing data.
• Specialty Topical Review: High-cost or specialized topical medications may be subject to utilization review and prospective authorization when clinical documentation is required.
• Refill Medical Necessity: Subsequent topical refills may be reviewed for continued medical necessity and may require updated clinical documentation from the authorized treating physician.

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

Compound Restrictions

• Itemized Billing: Compound prescriptions must be billed by component, with each active ingredient identified separately along with its quantity and NDC.
• Reasonable Value Pricing: Individual compound ingredients are evaluated based on the provider's submitted charge and the state's reasonable-value requirements under RSA 281-A:24, I(a). Invalid, missing, or dummy NDCs may result in the corresponding ingredient being assigned a $0 reimbursement value during bill review.
• Compounding Fee Limits: Because New Hampshire does not establish a formulaic pharmacy fee schedule for workers' compensation, pharmacies may not automatically apply multiple compounding or laboratory handling fees.
• Prior Authorization: Custom compounds may be subject to prospective authorization because of their non-routine nature and potential cost.

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

Timelines

• Pharmacy Billing Submission Deadline: Pharmacy bills should be submitted within 365 calendar days from the dispensing date in accordance with applicable New Hampshire workers' compensation billing requirements.
• Payer Payment/Denial Window: The employer or workers' compensation carrier generally has 30 calendar days after receiving a properly documented bill to issue payment or deny the charge.
• Dispute Resolution: Under RSA 281-A:24, I(c), the provider and carrier must first attempt to resolve disputes concerning reasonable value directly.
• Employee Hold-Harmless: The injured employee is not responsible for disputed workers' compensation pharmacy charges. Providers and collection entities may not pursue the employee for payment of covered charges.
• Formal NHDOL Hearing: If the dispute cannot be resolved directly, an interested party may petition the New Hampshire Department of Labor for a hearing under RSA 281-A:24, I(d).

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

Pricing Source

• Pharmacy Actual Billed Ledger & Regional Retail Cash Index

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

State Fee Schedule

• No Mandated Pharmacy Fee Schedule: New Jersey does not use a dedicated pharmacy fee schedule for workers' compensation prescriptions.
• Brand-Name Retail Pricing: Single-source brand-name medications are reimbursed based on the pharmacy's Usual & Customary (U&C) retail rate.
• Generic Retail Pricing: Multi-source generic medications are also priced according to the provider's U&C charge.
• Community Prevailing Rate Review: Under N.J.S.A. 34:15-15, pharmacy charges remain subject to review against prevailing community rates to determine whether billed amounts are reasonable.
• Physician Dispensing: Physician dispensing is generally limited to a seven-day supply unless the injured worker is more than 10 miles from the nearest pharmacy. These limits do not apply to traditional registered retail pharmacies.

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 operates under an employer-directed workers' compensation system. Under N.J.S.A. 34:15-15, the employer or workers' compensation carrier generally controls the selection of treating physicians, specialists, medical networks, and pharmacy channels for the claim.

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

Pre-Authorization

• No: New Jersey does not use a state pharmacy fee schedule for workers' compensation prescriptions. Reimbursement is generally based on the provider's usual and customary charge, subject to applicable reasonableness requirements.

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

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless accompanied by a valid signed prescription or clinical order from the authorized treating physician connecting the medication to the accepted workplace injury.
• U&C Pricing: Prescribed OTC medications are reimbursed based on the pharmacy's U&C charge, subject to prevailing community-rate review under N.J.S.A. 34:15-15.
• Handling Fees: New Jersey does not establish a formulaic dispensing fee for basic OTC transactions under this framework.
• Retroactive Review: Routine OTC medications do not require prospective authorization. However, the payer may retrospectively review the medication and deny reimbursement if it is excessive or unrelated to the workplace 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 Standalone Topical Schedule: New Jersey does not establish separate state-mandated reimbursement caps or quantity limits specifically for topical medications under this framework.
• U&C Pricing: Standalone prescription creams, ointments, gels, and transdermal products are reimbursed according to the pharmacy's U&C charge, subject to prevailing community-rate review under N.J.S.A. 34:15-15.
• Repackager NDC Review: Bill review systems may review NDC information and remove secondary repackager identifiers to verify the underlying manufacturer's pricing data.
• Specialty Topical Review: High-cost or specialized topical medications may be subject to utilization review and prospective authorization when clinical documentation is required.

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

Compound Restrictions

• Itemized Billing: Compound prescriptions must be billed by component, with each active ingredient separately identified along with its quantity and NDC.
• No Standalone Compound Schedule: New Jersey does not provide separate state-mandated reimbursement caps or quantity limits for compounded medications under this framework.
• U&C Ingredient Pricing: Individual compound ingredients are evaluated using the provider's U&C rate, subject to prevailing community pricing requirements under N.J.S.A. 34:15-15. Invalid, missing, or dummy NDCs may result in a $0 reimbursement value during bill review.
• Compounding Fee Restrictions: Pharmacies may not automatically add multiple compounding fees or custom laboratory labor premiums where no applicable fee schedule authorizes them.
• Prior Authorization: Custom compounds may be subject to prospective authorization because of their non-routine nature and potential cost.

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

Timelines

• Pharmacy Billing Submission Deadline: Pharmacy bills should be submitted within 365 calendar days from the dispensing date under applicable New Jersey workers' compensation billing requirements.
• Payer Payment/Action Window: Under N.J.S.A. 34:15-15, the employer or workers' compensation carrier generally has 60 calendar days after receiving a properly documented bill to issue payment or deny the charge.
• Employee Hold-Harmless: The injured employee is not responsible for disputed workers' compensation pharmacy charges for an accepted workplace injury. Providers and collection entities may not pursue the employee directly for payment.
• Medical Fee Dispute Deadline: Under N.J.S.A. 34:15-51, a medical provider may file a Medical Provider Application for Payment with the New Jersey Division of Workers' Compensation within six years from the date of service or last payment, as applicable.

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 Usual & Customary (U&C) Retail Master Profile & 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 Pricing Baseline: Outpatient prescriptions filled at a licensed retail pharmacy are priced using the published Average Wholesale Price (AWP) from recognized drug pricing sources such as Red Book or Medi-Span.
• Brand-Name Retail Formula: The maximum allowable payment for single-source brand-name or trade-name medications is AWP + $4.00.
• Generic Retail Formula: Multi-source generic medications are also reimbursed using AWP + $4.00.
• WAC Alternative: When an applicable AWP is unavailable, the pricing calculation may use Wholesale Acquisition Cost (WAC) × 1.2 as the alternative pricing basis.
• Lesser-Of Requirement: Maximum reimbursement is limited to the lowest applicable amount among the state fee schedule rate, the pharmacy's U&C charge, or a contracted network rate.

Sources: New Mexico Administrative Code (NMAC) Title 11, Chapter 4, Part 7 (11.4.7 NMAC); New Mexico Workers' Compensation Administration 2026 Provider Fee Schedule Manual; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide (March 2026 Update)

Direct Care

• Yes and No: New Mexico uses a dual-stage medical direction structure under NMSA 1978, 52-1-49. Either the employer or employee may make the initial selection of the primary treating physician.

Sources: New Mexico Statutes Annotated (NMSA) 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 utilizes the ODG Appendix A Drug Formulary. Medications classified with an "N" status require prospective authorization before dispensing.

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

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless accompanied by a valid signed prescription or clinical order from the authorized treating physician connecting the medication to the accepted workplace injury.
• AWP Pricing: Prescribed OTC medications are processed under the standard retail pharmacy formula of AWP + $4.00.
• Dispensing Fee: A standalone OTC item carries the applicable $4.00 dispensing fee. When an OTC ingredient is incorporated into a multi-ingredient compound, the completed prescription is evaluated under the compound reimbursement rules.
• Retroactive Review: Routine OTC medications do not require prospective authorization. However, the payer may retrospectively review the medication and deny reimbursement if it is excessive or unrelated to the workplace injury.

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

Topical Restrictions

• Standard Retail Pricing: Standalone commercial topical medications, including prescription creams, ointments, gels, and transdermal products, are reimbursed under the standard AWP + $4.00 formula.
• OTC Topical Caps: Under the updated 2026 cost-containment parameters:
  • Topical creams and ointments, excluding patches: Maximum reimbursement of $31.21 per 30-day supply, prorated as applicable.
  • Topical transdermal patches: Maximum reimbursement of $72.83 per 30-day supply, prorated as applicable.
• Repackager NDC Review: Bill review systems may remove secondary repackager NDCs and verify pricing against the primary manufacturer's AWP data.
• Topical Compound Cap: Customized prescription topical compounds are capped at the lesser of $200 per 30-day supply, prorated as applicable, or the amount allowed under the standard compound fee schedule.
• Specialty Topical Review: High-cost or specialized topical medications may require clinical documentation and prospective authorization when utilization thresholds are exceeded.

Sources: New Mexico Administrative Code 11.4.7 NMAC; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide (March 2026 Update)

Compound Restrictions

• Itemized Billing: Compound prescriptions must be billed by component, with each active ingredient separately identified along with its quantity and NDC.
• Compound Pricing Formula: Individual generic and brand-name ingredients are priced using the applicable compound formula of AWP × 0.90 + $5.00 professional dispensing fee per compound.
• Original Manufacturer NDC: Each compound ingredient must include the NDC of the original manufacturer or bulk chemical supplier. Repackager NDCs may be rejected during automated bill review and the ingredient may be repriced using the applicable lower-cost equivalent.
• Prior Authorization: Custom compounds may require prospective authorization because of their non-routine nature and potential cost.

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

Timelines

• Pharmacy Billing Submission Deadline: Pharmacy bills must be submitted within 90 calendar days from the dispensing date under applicable New Mexico workers' compensation billing requirements.
• Payer Payment/Action Window: The employer or workers' compensation carrier has 30 calendar days after receiving a properly documented bill to issue payment or formally deny the charge.
• Employee Hold-Harmless: The injured employee is not responsible for disputed workers' compensation pharmacy charges for an approved workplace injury. Providers and collection entities may not pursue the employee directly for payment.
• Billing Dispute Deadline: If a billing dispute cannot be resolved directly, the pharmacy must initiate the applicable dispute resolution process under 11.4.7 NMAC, including filing a Notice of Health Care Provider Billing Dispute within 90 days of receiving the partial payment or denial, as applicable.

Sources: New Mexico Administrative Code 11.4.7 NMAC (Billing Dispute Rules)

Pricing Source

• Red Book / Medi-Span AWP Master Database

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

State Fee Schedule

• AWP-Based Pricing: Outpatient prescriptions dispensed by licensed retail pharmacies are priced using the Average Wholesale Price (AWP) from recognized drug databases such as Red Book or Medi-Span.
• Brand-Name Pricing: Single-source brand-name medications are reimbursed at AWP × 0.88 + $4.00.
• Generic Pricing: Multi-source generic medications are reimbursed at AWP × 0.80 + $5.00.
• Lesser-of Pricing Rule: Final reimbursement is limited to the lowest of the applicable state fee schedule amount, the pharmacy's Usual & Customary (U&C) charge, or an applicable contracted network rate.
• Inpatient Medication Rule: Medications provided during an inpatient hospitalization are included in the hospital's facility reimbursement and are not billed separately through the outpatient pharmacy fee schedule.

Sources: New York Codes, Rules and Regulations (NYCRR) Title 12, Part 440 (12 NYCRR 440.2: Calculated Cost); New York State Workers' Compensation Board Subject Number 046-502; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Direct Care

• No: Unless an employer has established an authorized pharmacy network, the carrier must provide notice to the injured worker. Prescriptions must be filled through participating network pharmacies when a network is in place.

Sources: New York State Workers' Compensation Law (WCL) 13-a; WCL 13-p; 12 NYCRR 440.3

Pre-Authorization

• Yes: New York requires use of the Workers' Compensation Board Drug Formulary, which includes Phase A, Phase B, and perioperative drug categories. Non-formulary medications require a Prior Authorization Request (PAR) through the Medical Portal.

Source: 12 NYCRR 441.2 / New York Workers' Compensation Board Drug Formulary

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid written prescription or clinical order from the authorized treating physician that relates the medication to the accepted work injury.
• Electronic Billing Requirement: Prescribed OTC formulary medications must be processed through the carrier's electronic billing system or designated PBM rather than a standard consumer receipt.
• Generic Pricing: Valid OTC prescriptions are priced under the generic formula of AWP × 0.80 + $5.00, rather than public cash pricing.
• Lowest-Cost NDC Rule: When equivalent OTC products are available from multiple manufacturers, reimbursement is limited to the cost of the lowest-priced applicable 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 Topical Pricing: Commercial topical medications, including prescription creams, ointments, gels, and patches, follow the standard retail formulas of AWP × 0.88 + $4.00 for brand products and AWP × 0.80 + $5.00 for generic products.
• OTC Topical Caps: Under the 2026 WCB cost-containment parameters, OTC topical products are subject to the following maximums:
  • Creams and ointments, excluding patches: $31.21 per 30-day supply, prorated as applicable.
  • Transdermal patches: $72.83 per 30-day supply, prorated as applicable.
• Repackager NDC Review: Repackaged or private-label NDCs are reviewed against the primary manufacturer's pricing data to establish the applicable AWP.
• Medical Treatment Guidelines: Topical anti-inflammatory medications and specialized patches are subject to the New York Medical Treatment Guidelines (MTGs), including applicable frequency, duration, and diagnostic requirements.

Sources: New York State Workers' Compensation Board Medical Treatment Guidelines (MTGs); 12 NYCRR Part 440; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide (March 2026 Update)

Compound Restrictions

• Itemized Billing: Compounded prescriptions must identify each active ingredient separately, including its metric quantity and individual NDC.
• Ingredient Pricing: Brand ingredients are subject to AWP × 0.88, while generic ingredients are subject to AWP × 0.80. Invalid, missing, or dummy NDCs may be assigned a reimbursement value of $0.00.
• Compounding Fee Limitation: Pharmacies cannot add multiple compounding fees or separate labor premiums for individual ingredients. A single dispensing allowance applies to the transaction.
• Prior Authorization: Custom compounds are outside the automated formulary safe harbor and require prior authorization through the WCB Medical Portal before dispensing.

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 Submission Deadline: Retail pharmacies should submit properly coded bills electronically through NCPDP or on Form CMS-1500 within 120 calendar days of dispensing.
• Payer Payment Window: Under WCL 13-g, claims submitted to the carrier or self-insured employer are subject to a 45-day payment period.
• Disputed Claim Notice: When a pharmacy bill is partially or fully disputed, the payer must provide written notice to the Board, claimant, and pharmacy within 30 days, including the reason for nonpayment.
• Employee Protection: Pharmacies participating in workers' compensation claims must follow applicable fee schedule rates and may not balance-bill the injured employee.
• Dispute Resolution: A pharmacy disputing an underpayment or denial may file Form HP-1, Health Provider's Application for Arbitration of a Medical Bill, with the Workers' Compensation Board.

Sources: New York State Workers' Compensation Law (WCL) 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 Pricing: Outpatient brand and generic prescriptions dispensed by licensed retail pharmacies are priced using the Average Wholesale Price (AWP) applicable on the date of dispensing.
• Brand-Name Pricing: Single-source brand-name and trade-name medications are reimbursed at AWP × 0.95.
• Generic Pricing: Multi-source generic medications are also reimbursed at AWP × 0.95.
• Dispensing Fee: North Carolina does not provide a separate professional dispensing or handling fee for retail pharmacy prescriptions. The dispensing fee is $0.00.
• Lesser-of Pricing Rule: Final reimbursement is limited to the lowest of the state fee schedule amount, the pharmacy's U&C charge, or an applicable contracted network rate.

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

Direct Care

• Yes: North Carolina is an employer-directed state. Under N.C. Gen. Stat. 97-25, the employer or workers' compensation carrier has the authority to select treating providers, medical networks, and pharmacy fulfillment locations.

Sources: North Carolina General Statutes (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 operates under an open formulary model governed by NCIC rules and requires generic substitution for applicable multi-source medications.

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

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid written prescription or clinical order from the authorized treating physician connecting the medication to the accepted work injury.
• OTC Pricing: Prescribed OTC medications are processed under the standard retail formula of AWP × 0.95.
• Dispensing Fee: Retail pharmacies cannot add a separate professional handling or preparation fee to standalone OTC transactions. The dispensing fee remains $0.00.
• Retroactive Review: Although routine OTC prescriptions do not require prospective authorization, the carrier may conduct a retrospective review and deny items considered excessive or unrelated to the work injury.

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

Topical Restrictions

• Standard Topical Pricing: Commercial topical medications, including prescription creams, ointments, gels, and patches, are reimbursed under the standard AWP × 0.95 formula.
• Repackager NDC Review: Repackaged or private-label NDCs are reviewed against the primary manufacturer's pricing data to establish the applicable AWP.
• Specialty Topical Authorization: High-cost patches and specialized topical medications may require documentation of medical necessity and prospective authorization when utilization exceeds applicable guidelines.
• Refill Review: Subsequent topical refills may be subject to utilization review and require updated documentation supporting continued medical necessity.

Sources: North Carolina General Statutes (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

• Itemized Billing: Compounded prescriptions must identify each active ingredient separately, including the metric quantity and individual NDC.
• Ingredient Pricing: Compound ingredients are reimbursed at AWP × 0.95. Missing, invalid, or dummy NDCs may result in a $0.00 reimbursement value.
• Compounding Fee: Certain retail pharmacy compound transactions may qualify for a single specialized compounding fee under applicable carrier or PBM network terms. Multiple fees or unindexed laboratory charges cannot be stacked.
• Prior Authorization: Custom compounds are treated as non-routine medications and may require prior authorization through the applicable carrier or PBM.

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

Timelines

• Billing Submission Deadline: Retail pharmacies must submit properly coded pharmacy bills electronically through NCPDP or on Form CMS-1500 within 180 calendar days of dispensing.
• Payer Payment Window: Under N.C. Gen. Stat. 97-18(i), the payer has 60 calendar days from receipt of a properly documented bill to pay or deny the claim.
• Late-Payment Interest: Undisputed charges remaining unpaid after the 60-day period accrue statutory interest at 10% per year, beginning on the 61st day.
• Employee Protection: Injured workers are protected from direct collection efforts for accepted workplace injury claims.
• Dispute Resolution: If a billing dispute cannot be resolved directly, the pharmacy may file Form I.C. 33, Request that Claim be Assigned for Hearing, with the North Carolina Industrial Commission.

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

Pricing Source

• Red Book / Medi-Span AWP Master Database

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

State Fee Schedule

• WAC-Based Pricing: Retail prescriptions are priced using the Wholesale Acquisition Cost (WAC) from the Wolters Kluwer Medi-Span electronic drug database.
• Brand-Name Pricing: Single-source brand-name medications are reimbursed at WAC × 1.08 + $4.00.
• Generic Pricing: Multi-source generic medications are reimbursed at the lower of WAC × 1.08 + $5.00 or MAC × 1.05 + $5.00.
• Lesser-of Pricing Rule: Final reimbursement is limited to the lowest applicable state fee schedule amount, pharmacy U&C charge, or contracted network rate.

Sources: North Dakota Administrative Code (NDAC) 92-01-02-45.1; North Dakota Workforce Safety & Insurance (WSI) Pharmacy Services Fee Schedule; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Direct Care

• Yes: North Dakota operates through Workforce Safety & Insurance (WSI), which administers the state's workers' compensation system and controls medical care authorization and cost-containment requirements.

Sources: North Dakota Century Code (NDCC) 65-05-28; North Dakota WSI Pharmacy Services Guidelines and First Fill Program Specifications

Pre-Authorization

• Yes: North Dakota uses a state-specific closed drug formulary. Prior approval is required for medications outside the preferred tiers.

Source: N.D. Cent. Code 65-05-07 / Workforce Safety & Insurance

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid prescription or clinical order from an approved treating physician that connects the medication to the accepted work injury.
• Electronic Billing: Prescribed OTC medications must be processed through standard NCPDP pharmacy transactions.
• OTC Pricing: Reimbursement is limited to the lower of the applicable generic formula, WAC × 1.08 + $5.00 or MAC × 1.05 + $5.00, or the pharmacy's U&C price.

Sources: North Dakota WSI Pharmacy Services Manual; North Dakota Administrative Code (NDAC) 92-01-02-45.1

Topical Restrictions

• Compound Strength Limits: Customized topical compounds are subject to maximum ingredient strengths, including:
  • Lidocaine: 5%
  • Ketamine: 10%
  • Gabapentin: 6%
  • Amitriptyline: 7%
  • Cyclobenzaprine: 3%
  • Baclofen: 5%
• Piroxicam Limitation: Topical piroxicam is limited to a maximum strength of 3% and is reimbursable only for verified plantar fasciitis.
• Commercial Topical Pricing: Non-compounded prescription topicals follow the standard fee schedule of WAC × 1.08 + $4.00 for brand products and WAC × 1.08 + $5.00 for generic products.
• Repackager NDC Review: Secondary repackaged NDCs are removed from the pricing review, with reimbursement based on the primary manufacturer's pricing data.

Sources: North Dakota Workforce Safety & Insurance (WSI) Topical Medication and Compounding Guidelines Manual

Compound Restrictions

• Ingredient Limit: Compounded prescriptions may contain no more than 5 active ingredients.
• Total Strength Limit: The combined strength of all active ingredients may not exceed 30%.
• Quantity Limits: Initial fills are limited to 60 grams for 15 days, while subsequent fills are limited to 120 grams for 30 days.
• Compound Pricing: Approved compounds are reimbursed using AWP minus 72%.
• Compounding Labor Fees: A single labor fee applies based on preparation complexity:
  • Level 1, Mixing Liquids: $10.00
  • Level 2, Triturating Powder or Hand-Mixing Ointments: $15.00
  • Level 3, Molds, Melt Bases, or Capsules: $20.00
  • Level 4, USP 797 Sterile Compounding: $25.00
• Prior Authorization: Compounded medications require a Medication Prior Authorization Request using Form M11 before processing.

Sources: North Dakota Workforce Safety & Insurance (WSI) Compound/Formulary Product Restrictions and Quantity Limitations Register

Timelines

• Billing Submission Deadline: Retail pharmacies must submit electronic NCPDP bills within 365 calendar days of the date of service.
• Payer Payment Window: WSI has 30 calendar days from receipt of a properly documented bill to pay or issue a formal denial.
• Employee Protection: Injured workers may not be balance-billed or directly pursued for payment on accepted workplace injury claims.
• Dispute Resolution: Pharmacies disputing a WSI payment decision must submit a written Request for Reconsideration to WSI's Medical Provider Grievance unit within 30 days of the initial remittance advice.

Sources: North Dakota Century Code (NDCC) Title 65; North Dakota Administrative Code (NDAC) Title 92

Pricing Source

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

Sources: North Dakota Century Code 65-02-01; North Dakota Administrative Code 92-01-02-45.1; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

State Fee Schedule

• AWP-Based Pricing: Outpatient legend prescriptions dispensed by enrolled retail pharmacies are priced using the AWP applicable on the date of dispensing.
• Brand-Name Pricing: Single-source brand-name medications are reimbursed at AWP × 0.85 + $3.50.
• Generic Pricing: Generic medications are reimbursed at the lower of AWP × 0.85 + $3.50 or the applicable BWC Maximum Allowable Cost (MAC).
• Lesser-of Pricing Rule: Final reimbursement is limited to the lowest of the applicable state fee schedule amount, pharmacy U&C charge, or contracted network rate.

Sources: Ohio Administrative Code (OAC) 4123-6-21; Ohio Bureau of Workers' Compensation (BWC) Outpatient Fee Adjustments; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide (March 2026 Update)

Direct Care

• Yes: Ohio's workers' compensation system uses Managed Care Organizations (MCOs) to manage medical care. The employer's designated MCO has authority to direct care, manage provider networks, and administer authorization requirements.

Sources: Ohio Administrative Code (OAC) 4123-6-02 and 4123-6-21; Ohio BWC Provider Billing and Enrollment Instructions

Pre-Authorization

• Yes: Ohio uses the BWC Outpatient Drug Formulary, which identifies medications as allowed or denied and establishes applicable authorization requirements.

Source: Ohio Administrative Code 4123-6-21 / Ohio BWC Formulary

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid prescription or clinical order from the authorized treating physician connecting the medication to the allowed work injury.
• Electronic Billing: Prescribed OTC medications must be submitted electronically through standard NCPDP transactions and the centralized PBM system.
• Generic Pricing: Valid OTC prescriptions are reimbursed at the lower of AWP × 0.85 + $3.50 or the pharmacy's U&C price.
• Employee Protection: Pharmacies accepting workers' compensation claims must follow applicable fee schedule rates and may not balance-bill the injured worker for an allowed claim.

Sources: Ohio Administrative Code (OAC) 4123-6-21 and 4123-6-21.1(F); BWC Injured Worker Outpatient Medication Guidelines

Topical Restrictions

• Standard Topical Pricing: Commercial topical medications are reimbursed under the standard formula of AWP × 0.85 + $3.50 for applicable brand and generic lines.
• Repackager NDC Review: Repackaged or private-label NDCs are removed from the pricing review, with reimbursement based on the primary manufacturer's AWP.
• Formulary Quantity Limits: Topical anti-inflammatory medications and specialized patches are subject to BWC formulary quantity and days' supply limits.
• Medical Necessity Authorization: High-cost patches and specialized topical medications may require documentation of medical necessity and prospective authorization.

Sources: Ohio Administrative Code (OAC) 4123-6-21.1; Ohio Bureau of Workers' Compensation Outpatient Medication Formulary Quantity Limits

Compound Restrictions

• Itemized Billing: Compounded prescriptions must identify each active ingredient separately through the electronic NCPDP transaction, including the metric quantity and individual NDC.
• Ingredient Pricing: Approved compound ingredients are priced at AWP × 0.85 or the applicable BWC maximum allowable cost. Invalid or repackaged NDCs may result in a $0.00 reimbursement.
• Compounded Product Cap: The product cost for a single non-sterile compounded prescription is capped at $100.
• Compounding Fees: Compounding fees are tiered by preparation complexity:
  • Non-sterile / Low Complexity: $18.75
  • Sterile / High Complexity: $37.50
• Frequency Limit: Reimbursement is limited to one non-sterile compounded prescription per 30-day period.

Sources: Ohio Administrative Code (OAC) 4123-6-21 and 4123-6-21.1; Ohio BWC Outpatient Medication Payment Revisions (Effective February 1, 2026)

Timelines

• Billing Submission Deadline: Retail pharmacies must submit properly coded electronic NCPDP pharmacy bills within 365 calendar days of the date of service.
• Payer Payment Window: The payer has 30 calendar days from receipt of a properly documented bill to process payment or issue a formal denial.
• Employee Protection: Injured workers are protected from balance billing and direct collection efforts for allowed workplace injury claims.
• Dispute Resolution: Pharmacies disputing an MCO payment decision must submit an MCO Medical Dispute Resolution Request to the applicable MCO within 30 days of the initial denial before pursuing further administrative review.

Sources: Ohio Administrative Code (OAC) 4123-6-21.1(I)(6); Ohio Revised Code (ORC) 4123.511; BWC Medical Provider Dispute Guidelines

Pricing Source

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

Sources: Ohio Administrative Code (OAC) Title 4123, Chapter 6; Ohio Bureau of Workers' Compensation Enforcement Division; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

State Fee Schedule

• AWP-Based Pricing: Outpatient prescriptions filled at licensed retail pharmacies are reimbursed under the Oklahoma Workers' Compensation Fee Schedule in Title 810, Chapter 15. Pricing is based on nationally recognized drug databases.
• Brand and Generic Formula: Both single-source brand-name and multi-source generic medications are reimbursed at AWP × 0.90 + $5.00 professional dispensing fee.
• Lesser-of Pricing Rule: Final reimbursement is the lowest of the calculated fee schedule amount, the pharmacy's submitted Usual & Customary (U&C) charge, or a contracted network rate.
• MAC Pricing for Generics: Generic medications are also reviewed against applicable Maximum Allowable Cost (MAC) pricing. When the MAC amount is lower than the calculated fee schedule rate, reimbursement is reduced accordingly.

Sources: Oklahoma Administrative Code (OAC) Title 810, Chapter 15, Subchapter 5; Oklahoma Workers' Compensation Commission (WCC) Fee Schedule Ground Rules; Optum Workers' Compensation Pharmacy Resource Guide

Direct Care

• Yes: Oklahoma allows employers to participate in Certified Workplace Medical Plans (CWMPs). When an employer has an approved CWMP, the employer or carrier may establish the provider panel and direct the employee's medical care.

Sources: Oklahoma Statutes (O.S.) Title 85A, §64; OAC 810:15-5-1

Pre-Authorization

• Yes: Oklahoma uses a closed drug formulary. Excluded medications, custom compounds, and certain specialty or controlled medications require prospective prior authorization.

Source: Okla. Stat. tit. 85A, §50; Oklahoma Workers' Compensation Commission

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid signed prescription or clinical order from the authorized treating physician.
• Strength and Quantity Requirements: When prescribing an OTC medication, the physician must indicate the appropriate strength and approximate quantity reasonably required for the work-related injury.
• OTC Pricing: Validly prescribed OTC medications are processed under the standard pharmacy pricing formula. Reimbursement is the lower of AWP × 0.90 + $5.00 or the pharmacy's U&C charge.
• No Additional Surcharges: Pharmacies may not add separate compounding, laboratory, or custom handling fees to a standalone OTC transaction.

Sources: OAC 810:15-5-1(b); Optum Workers' Compensation Pharmacy Resource Guide

Topical Restrictions

• Standard Topical Pricing: Non-compounded prescription creams, ointments, gels, and patches are reimbursed using the standard formula of AWP × 0.90 + $5.00.
• Topical Compound Cap: Customized topical compounds are limited to the lesser of $200 for a 30-day supply, prorated as needed, or the amount allowed under the applicable fee schedule.
• OTC Topical Limits: OTC creams and lotions are limited to $30 for a 30-day supply, while OTC patches are limited to $75 for a 30-day supply, prorated as needed.
• NDC Verification: Repackager and private-label NDCs are removed during bill review, with pricing verified against the primary manufacturer's source data.

Sources: Oklahoma Workers' Compensation Commission (WCC) 2026 Medical Fee Schedule Rules; Optum Workers' Compensation Pharmacy Resource Guide

Compound Restrictions

• Itemized Billing: Compound prescriptions must be billed by individual ingredient, including the ingredient name, exact metric weight, and NDC.
• Ingredient Pricing: Individual compound ingredients are priced at AWP × 0.90. Missing, invalid, or dummy NDCs are reduced to $0.00.
• Single Dispensing Fee: A retail pharmacy may apply one professional dispensing fee to the compound. Multiple compounding fees or additional unindexed laboratory charges are not permitted.
• Prior Authorization: Custom compounds require prior authorization before the pharmacy can process the prescription through the retail pharmacy network.

Sources: Oklahoma Workers' Compensation Commission Medical Fee Schedule Ground Rules; Optum Workers' Compensation Pharmacy Resource Guide

Timelines

• Billing Deadline: Retail pharmacies should submit properly coded electronic bills within 365 calendar days of dispensing. Late submissions may be subject to administrative denial.
• Payer Payment Window: The carrier or third-party administrator generally has 30 calendar days after receiving a properly documented bill to pay or formally deny the charge.
• Employee Protection: For an approved work-related injury, the injured employee is protected from balance billing for covered pharmacy charges.
• Dispute Resolution: If a billing dispute cannot be resolved directly, the pharmacy may file Form 19, Request for Payment of Medical Charges, with the Oklahoma Workers' Compensation Commission.

Sources: Oklahoma Statutes Title 85A, §50; Oklahoma Workers' Compensation Commission Administrative Rules

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: Oklahoma Statutes Title 85A; Oklahoma Workers' Compensation Commission; Optum Workers' Compensation Pharmacy Resource Guide

State Fee Schedule

• AWP-Based Pricing: Outpatient brand-name and generic prescriptions filled at licensed retail pharmacies are priced using the published Average Wholesale Price (AWP) on the date of dispensing.
• Brand-Name Formula: Single-source brand-name medications are reimbursed at AWP × 0.85 + $2.00.
• Generic Formula: Multi-source generic medications are reimbursed at AWP × 0.80 + $2.00.
• Lesser-of Pricing Rule: Final reimbursement is the lowest of the applicable fee schedule amount, the pharmacy's U&C charge, or a contracted network rate.
• MAC Pricing: Generic prescriptions are also reviewed against applicable state Maximum Allowable Cost (MAC) pricing. When the MAC amount is lower, it becomes the reimbursement basis.

Sources: Oregon Administrative Rules (OAR) Chapter 436, Division 009; Oregon Workers' Compensation Division (WCD) Maximum Allowable Payment Tables; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide, March 2026 Update

Direct Care

• No: Oregon generally allows injured workers to select their primary treating provider and pharmacy under ORS 656.245.
• MCO Exception: If the employer participates in a state-certified Workers' Compensation Managed Care Organization (MCO), the worker may be required to use approved providers or designated network locations.

Sources: Oregon Revised Statutes (ORS) 656.245; OAR Chapter 436, Division 015; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Pre-Authorization

• No: Oregon generally follows an open formulary model under Workers' Compensation Division rules, with generic substitution and utilization controls.

Source: ORS 656.245; Oregon Workers' Compensation Division Administrative Rules

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid signed prescription or clinical order connecting the medication to the accepted work-related injury.
• OTC Pricing: Prescribed OTC medications are evaluated under a retail-based pricing structure rather than the standard AWP prescription formula.
• Retail Price Limit: Automated bill review systems compare the submitted amount with the actual retail shelf price or the provider's standard fee and apply the lower amount.
• Electronic Billing: Prescribed OTC medications must be submitted electronically through standard NCPDP transactions and the applicable carrier or PBM network.

Sources: OAR Chapter 436, Division 009; Oregon Workers' Compensation Division Medical Fee Guidelines; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Topical Restrictions

• Standard Topical Pricing: Non-compounded topical medications are reimbursed at AWP × 0.85 + $2.00 for brand-name products and AWP × 0.80 + $2.00 for generic products.
• NDC Verification: Repackager and private-label NDCs are removed during bill review, with the pricing baseline verified against the original manufacturer's AWP.
• Specialty Topicals: High-cost transdermal patches and specialized anti-inflammatory gels may be subject to utilization review and prior authorization when they exceed applicable guidelines.

Sources: OAR Chapter 436, Division 009; Oregon Workers' Compensation Division Payment Tables; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Compound Restrictions

• Itemized Billing: Compound prescriptions must be billed by individual ingredient, including metric weight and NDC information, through electronic NCPDP transactions.
• Ingredient Pricing: Brand ingredients are reimbursed at AWP minus 15%, while generic ingredients are reimbursed at AWP minus 20%. Invalid or missing NDCs are reduced to $0.00.
• Single Compounding Fee: A single $10.00 compounding fee applies to the ingredient total and includes the dispensing fee. Separate professional modifiers may not be stacked.
• Prior Authorization: Custom compounds require prior authorization before processing through the retail pharmacy network.

Sources: OAR Chapter 436, Division 009; Oregon Workers' Compensation Division Medical Fee Manual Ground Rules; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Timelines

• Billing Deadline: Retail pharmacies should submit properly coded bills within 365 calendar days of dispensing. Late submissions may be subject to administrative denial.
• Payer Payment Window: The carrier or self-insured employer has 45 calendar days after receiving a properly documented bill to pay or formally deny the charge.
• Employee Protection: Providers must bill the insurer for covered workers' compensation services and may not balance bill the injured employee.
• Dispute Resolution: Unresolved billing disputes may be submitted to the Workers' Compensation Division Medical Resolution Team through a formal administrative review request within 90 calendar days of the denial.

Sources: ORS Chapter 656; OAR Chapter 436, Division 009; Oregon WCD Medical Resolution Team Dispute Guidelines

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: OAR Chapter 436, Division 009; Oregon Department of Consumer and Business Services (DCBS); Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

State Fee Schedule

• Brand-Name Formula: Outpatient brand-name and single-source prescriptions filled at retail pharmacies are priced using AWP at AWP × 0.85 + $4.00.
• Generic Formula: Multi-source generic products and non-drug retail supplies are priced at AWP × 0.60 + $4.00.
• Lesser-of Pricing Rule: Final payment is the lowest of the applicable federal fee schedule amount, the pharmacy's U&C charge, or a contracted network rate.
• Electronic Remittance: Retail pharmacy payments are processed through electronic systems, with 835 remittance information supporting prescription and dispensing reconciliation.

Sources: U.S. Department of Labor (DOL) Office of Workers' Compensation Programs (OWCP) Pharmacy Bill Processing Portal Announcements; Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

Direct Care

• Yes: OWCP administers federal workers' compensation programs, including FECA, the Black Lung Program, and EEOICPA. Federal rules govern pharmacy coverage, provider enrollment, and payment rather than state-level employer direction requirements.

Sources: Title 20 CFR 10.805; U.S. DOL OWCP New Provider Enrollment Training Presentation; FECA Claimant Prescription Guide

Pre-Authorization

• Yes: OWCP uses a centralized pharmacy billing and utilization framework. Certain high-risk medications, compounds, and specialty therapies may require prior authorization before payment.

Source: DOL OWCP WCMBP Portal Directives; Updated April 2026 Authorization Templates

OTC Restrictions

• Prescription Requirement: OTC medications and non-legend retail supplies are not reimbursable unless supported by a valid signed prescription or clinical order from the authorized treating physician.
• Generic Pricing: Validly prescribed OTC medications are reimbursed at AWP × 0.60 + $4.00.
• Electronic Billing: Prescribed OTC medications must be submitted electronically through standard NCPDP transactions and the applicable pharmacy network or PBM.

Sources: U.S. Department of Labor OWCP Pharmacy Fee Schedule Guidelines; Conduent Retail Adjudication Standards

Topical Restrictions

• Standard Topical Pricing: Non-compounded topical medications are reimbursed at AWP × 0.85 + $4.00 for brand-name products and AWP × 0.60 + $4.00 for generic products.
• NDC Verification: Repackager and private-label NDCs are removed during bill review, with pricing verified against the original manufacturer's AWP.
• Quantity Limits: High-cost transdermal patches and anti-inflammatory topical gels may be subject to quantity and days' supply limits under applicable OWCP utilization protocols.

Sources: U.S. Department of Labor OWCP Pharmacy Fee Schedule Guidelines; Conduent Automated Bill Review Rules

Compound Restrictions

• Itemized Billing: Compound prescriptions must be billed by individual ingredient through electronic NCPDP transactions, including metric weight and NDC information.
• Compound Pricing: Compound ingredients are reimbursed at AWP × 0.30 + $4.00.
• Single Dispensing Fee: Pharmacies may not add separate compounding labor fees or multiple dispensing modifiers. A single $4.00 dispensing fee applies to the compound transaction.
• Prior Authorization: Compounds require prior authorization before they can be processed through the retail pharmacy network.

Sources: U.S. Department of Labor OWCP Pharmacy Fee Schedule Guidelines; OWCP Medical Fee Schedule Data Files

Timelines

• Billing Deadline: Enrolled retail pharmacies should submit properly coded electronic bills through the NCPDP real-time system on the date of dispensing.
• Electronic Payment: OWCP-enrolled pharmacy providers must maintain active Electronic Fund Transfer (EFT) information. The Department of Labor does not issue paper checks for these payments.
• Employee Protection: Pharmacies may not balance bill or collect covered charges directly from an injured employee for an approved claim.
• Fee Reconsideration: Pharmacies disputing a payment reduction may submit a written Request for Fee Reconsideration to OWCP within 30 days of the payment or remittance date.

Sources: Title 20 CFR 10.812; U.S. Treasury Electronic Fund Transfer Mandate; Executive Order 14247

Pricing Source

• Red Book Master AWP Database

Sources: Title 20 CFR Chapter I; U.S. Department of Labor OWCP Official Administrative Directories; Optum Workers' Compensation Fee Schedule Resource Guide

State Fee Schedule

• AWP-Based Pricing: Outpatient legend prescriptions filled at licensed retail pharmacies are priced using the AWP in effect on the date of dispensing.
• Brand and Generic Formula: Both brand-name and generic medications are reimbursed at AWP × 1.10.
• Lesser-of Pricing Rule: Final reimbursement is the lowest of the calculated fee schedule amount, the pharmacy's U&C charge, or a contracted network rate.
• WAC Alternative: When an applicable AWP is unavailable, the pricing baseline changes to WAC × 1.20.

Sources: Pennsylvania Workers' Compensation Act §306(f.1)(3)(vi)(A); Optum Pharmacy Resource Guide, Workers' Compensation, March 2026

Direct Care

• Yes: Pennsylvania follows a dual-stage medical choice model. When an employer meets the applicable statutory requirements, it may direct medical care through a designated provider panel for the first 90 days following the injury.

Sources: Pennsylvania Workers' Compensation Act §306(f.1)(1)(i); Supreme Court of Pennsylvania, June 16, 2026 ruling in 700 Pharmacy v. Bureau of Workers' Compensation Fee Review Hearing Office

Pre-Authorization

• Yes: Pennsylvania uses the ODG Drug Formulary. Medications designated ODG-Yes may process through standard channels, while ODG-No medications require prospective prior authorization.

Source: 77 Pa. Stat. §531; Pennsylvania Bureau of Workers' Compensation

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless supported by a valid signed prescription or clinical order connecting the medication to the accepted work-related injury.
• Electronic Billing: Prescribed OTC medications must be submitted electronically through standard NCPDP transactions and the applicable carrier or PBM network.
• OTC Pricing: Validly prescribed OTC medications are reimbursed at the lower of AWP × 1.10 or the pharmacy's submitted U&C price.

Sources: Pennsylvania Workers' Compensation Act §306(f.1)(3)(vi); Optum Pharmacy Resource Guide, Workers' Compensation, March 2026

Topical Restrictions

• Standard Topical Pricing: Non-compounded topical medications are reimbursed under a lesser-of formula using AWP × 1.10 or the applicable CMS Federal Upper Limit (FUL).
• NDC Verification: Repackager and private-label NDCs are removed during bill review, with pricing verified against the original manufacturer's AWP.
• OTC Topical Limits: Standard creams, lotions, and gels are limited to $31.21 for a 30-day supply, while topical patches are limited to $72.83 for a 30-day supply, prorated as needed.
• Topical Compound Cap: Customized topical compounds are subject to a maximum product reimbursement of $200 for a 30-day supply, prorated as needed.

Sources: Pennsylvania Workers' Compensation Act §306(f.1)(3)(vi)(G.2); Pennsylvania Senate Bill 1215 Data Registers; Optum Pharmacy Resource Guide, Workers' Compensation, March 2026

Compound Restrictions

• Itemized Billing: Compound prescriptions must be billed by individual ingredient through electronic NCPDP transactions, including metric weight and NDC information.
• Ingredient Pricing: Each approved ingredient is reimbursed at AWP × 1.10. Missing, invalid, or unrecognized NDCs are reduced to $0.00.
• Compounding Fee: An authorized compound may include one $20.00 compounding modifier per prescription.
• Product Cost Cap: Total compound ingredient reimbursement may not exceed $400 for a 30-day supply, prorated as needed.
• Commercial Duplicate Exclusion: A compound that duplicates an FDA-approved commercially available drug is not reimbursable.

Sources: Pennsylvania Workers' Compensation Act §306(f.1)(3)(vi)(G.1); Pennsylvania Senate Bill 1215 Data Registers, effective 2026 updates

Timelines

• Billing Deadline: Retail pharmacies should submit properly coded bills within 365 calendar days of dispensing. Late submissions may be subject to administrative denial.
• Payer Payment Window: The carrier, third-party administrator, or self-insured employer has 30 calendar days after receiving a properly documented bill to pay or deny the charge.
• Employee Protection: Providers must bill the insurer for covered workers' compensation services and may not balance bill the injured employee.
• Fee Review: Pharmacies disputing an adverse payment decision may file Form LIBC-507, Application for Fee Review, with the Bureau of Workers' Compensation Fee Review Hearing Office within 90 days of the adverse remittance advice.

Sources: 34 Pennsylvania Code Chapter 127; Pennsylvania Bureau of Workers' Compensation Form LIBC-507 Procedures

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: Title 77 Pennsylvania Statutes §531; Pennsylvania Department of Labor & Industry Bureau Guidelines; Optum Pharmacy Resource Guide, Workers' Compensation, March 2026

State Fee Schedule

• Closed Financial System: Puerto Rico does not use retail storefront percentage formulas or AWP-based multipliers for standard workers' compensation pharmacy billing because independent retail pharmacies do not process these transactions.
• Internal Public Dispensing System: Covered prescriptions are processed through government-operated pharmacy centers, regional dispensaries, and the central Industrial Hospital in San Juan.
• $0.00 Storefront Fee Schedule: Because open retail fulfillment is not permitted under Law No. 45, external fee schedule amounts, professional handling fees, and dispensing fee modifiers are set at $0.00.
• Lesser-Of Audit Gate: Since external retail billing is administratively prohibited, third-party bill review systems reject submitted brand, generic, and compound retail drug lines as out-of-system transactions.

Sources: Ley de Compensaciones por Accidentes del Trabajo (Law No. 45), Corporación del Fondo del Seguro del Estado (CFSE) General Regulations, CFSE Internal Pharmacy Operations Manual

Direct Care

• Yes: Puerto Rico operates under a monopolistic workers' compensation system under Law No. 45. Employers must obtain coverage through the CFSE, while private workers' compensation carriers are not permitted to provide coverage on the island. Injured workers receive care through CFSE regional dispensaries and designated facilities.

Sources: Ley de Compensaciones por Accidentes del Trabajo (Law No. 45), CFSE Network Care Direction Guides, CFSE Web Portal Services

Pre-Authorization

• Yes: Puerto Rico uses a centralized closed outpatient formulary administered by the CFSE. Storefront pharmacies must route prescriptions through designated electronic systems. High-cost brand medications, compounds, and specialty drugs may require prospective authorization from a CFSE medical director.

Source: Puerto Rico Act No. 45-1935 (Ley de Compensación por Accidentes del Trabajo)

OTC Restrictions

• Prescription Requirement: OTC or non-legend medications are not reimbursable or dispensable unless supported by a formal clinical order from an authorized CFSE physician.
• Closed Distribution Path: Approved OTC medications, including basic analgesics, creams, and anti-inflammatories, are distributed through CFSE pharmacy inventory during the patient's evaluation or treatment.
• Retail Purchase Restriction: Injured workers cannot purchase OTC medications from commercial retailers and submit receipts to CFSE for reimbursement. Unauthorized retail transactions are not reimbursable.

Sources: Corporación del Fondo del Seguro del Estado (CFSE) Outpatient Pharmacy Operational Rules, CFSE Internal Billing Guidelines

Topical Restrictions

• Formulary Requirement: Commercial topical medications, including prescription creams, ointments, and transdermal patches, must appear on the active CFSE formulary to be dispensed.
• Point-of-Care Distribution: Authorized topical medications are dispensed directly through CFSE facilities following evaluation or rehabilitation services.
• Quantity and Diagnostic Limits: CFSE pharmacy systems apply quantity controls and limit topical medications to the units necessary to treat the accepted work-related condition.

Sources: Corporación del Fondo del Seguro del Estado (CFSE) Internal Medical Guidelines, CFSE Regional Office Formulary Edits

Compound Restrictions

• Restricted Compound Distribution: Custom compounded medications are heavily restricted because commercial retail fulfillment is unavailable under the state fund system.
• Centralized Industrial Hospital Pathway: When a customized compound is clinically necessary and cannot be fulfilled by a commercially manufactured drug, the prescription is routed through the CFSE Industrial Hospital pharmacy in San Juan.
• External Fee Restriction: Because compounding is handled internally, external compounding labor and handling fees are not reimbursable and are set at $0.00.

Sources: Ley de Compensaciones por Accidentes del Trabajo (Law No. 45), CFSE Industrial Hospital Specialized Pharmacy Protocol Logs

Timelines

• Closed-System Billing: Because pharmacy services are handled internally by CFSE physicians and pharmacists, traditional pharmacy billing submission deadlines and prompt-pay penalties do not apply.
• Employer Premium Payments: Employers must pay required CFSE insurance premiums twice annually based on their risk classification and payroll size to maintain statutory protections.
• Injured Worker Appeals: An injured worker challenging a medical necessity determination or formulary denial must file an administrative appeal with the Puerto Rico Industrial Commission within 30 calendar days of receiving formal notice.

Sources: Ley de Compensaciones por Accidentes del Trabajo (Law No. 45), Ley de Procedimiento Administrativo Uniforme de Puerto Rico, Reglamento General de la Comisión Industrial de Puerto Rico

Pricing Source

• CFSE Centralized Institutional Purchasing Inventory Ledger

Sources: Ley de Compensaciones por Accidentes del Trabajo (Law No. 45), Puerto Rico Department of Labor and Human Resources (DTRH), Optum Workers' Compensation Fee Schedule Resource Guide

State Fee Schedule

• AWP Pricing Ceiling: Outpatient brand-name and generic prescriptions filled at licensed retail pharmacies are priced using the published AWP applicable on the dispensing date.
• Brand and Generic Formula: Both single-source brand and multi-source generic medications are capped at AWP × 0.90.
• Actual Cost Rule: When a pricing dispute occurs, the pharmacy may submit its actual acquisition invoice. Reimbursement may be based on the actual drug cost multiplied by 0.90.
• Lesser-Of Audit Gate: Final reimbursement is the lesser of the pharmacy's submitted U&C charge, the applicable maximum payment amount, or AWP × 0.90.

Sources: Rhode Island Workers' Compensation Medical Fee Schedule Rules and Pharmacy Guidelines, Rhode Island Department of Labor and Training Division of Workers' Compensation Rules, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Direct Care

• No: Rhode Island generally follows an employee-choice model for initial medical care. The injured worker may select the initial treating physician or licensed pharmacy.

Sources: Rhode Island General Laws (R.I. Gen. Laws) Title 28 Chapter 33 Section 8, Rhode Island DLT Division of Workers' Compensation Administrative Guidelines, Rhode Island Workers' Compensation Fee Schedule Rules

Pre-Authorization

• No: Rhode Island uses an open formulary framework with carrier-specific utilization controls. Single-source brand medications may be subject to automated substitution requirements.

Source: R.I. Gen. Laws 28-33-5 / DLT Administrative Rules

OTC Restrictions

• Prescription Requirement: OTC or non-legend medications are not reimbursable unless supported by a valid prescription or clinical order from the authorized treating physician.
• Electronic NCPDP Billing: Prescribed OTC medications must be submitted through standard electronic NCPDP transactions rather than manual receipts or paper logs.
• Retail Cost Limit: Reimbursement for approved OTC prescriptions is limited to the published AWP × 0.90 or the pharmacy's submitted U&C price, whichever is lower.

Sources: Rhode Island Workers' Compensation Medical Fee Schedule Rules and Pharmacy Guidelines, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Pricing: Non-compounded topical medications, including prescription creams, ointments, gels, and patches, are subject to the standard AWP × 0.90 reimbursement limit.
• NDC Requirement: Topical pharmacy bills must include the applicable NDC and exact quantity dispensed.
• Original Manufacturer NDC: Bill review systems may cross-reference topical products against the original manufacturer's NDC to prevent inflated pricing from repackagers or private-label distributors.

Sources: Rhode Island Workers' Compensation Medical Fee Schedule Rules and Pharmacy Guidelines, Rhode Island Department of Labor and Training Division of Workers' Compensation Rules

Compound Restrictions

• Ingredient-Level Billing: Compounded medications must be billed on a single bill with each ingredient listed separately, including quantity and charge.
• Ingredient Pricing: Each ingredient is reimbursed under the existing pharmacy fee schedule at AWP × 0.90. Ingredients without a valid NDC are not reimbursable.
• Original Manufacturer NDC: Repackaged ingredients must use the original manufacturer's NDC.
• Topical Compound Requirement: Ingredients used in topical compounds must be FDA-approved for topical use to qualify for reimbursement.
• $500 Compound Maximum: Topical compound reimbursement is limited to $500 per prescription for a 30-day supply, prorated when applicable. The reimbursable amount is the lesser of the U&C charge, $500, or AWP × 0.90.

Sources: Rhode Island Workers' Compensation Medical Fee Schedule Rules and Pharmacy Guidelines, Rhode Island Department of Labor and Training Division of Workers' Compensation Rules

Timelines

• Billing Submission Deadline: Licensed retail pharmacies must submit properly coded bills within 365 calendar days of dispensing.
• Payer Payment Window: The carrier or self-insured employer has 21 calendar days after receiving a properly documented bill to pay or formally deny the charge.
• Employee Hold-Harmless: Providers cannot balance-bill an injured worker for amounts related to an allowed workers' compensation claim.
• Medical Review Appeal: A pharmacy disputing a payment reduction or denial must file a Petition for Medical Review with the Rhode Island Workers' Compensation Court within 1 year of the adverse remittance advice.

Sources: Rhode Island General Laws (R.I. Gen. Laws) Title 28 Chapter 33 Section 9, Rhode Island Workers' Compensation Court Rules of Procedure

Pricing Source

• Red Book / Medi-Span AWP Master Database

Sources: R.I. Gen. Laws Title 28, Rhode Island Department of Labor and Training Division Guidelines, Optum Workers' Compensation Pharmacy Fee Schedule Resource Guide

State Fee Schedule

• AWP Pricing Ceiling: Outpatient brand and generic prescriptions filled at licensed retail pharmacies are priced using the published AWP applicable on the dispensing date.
• Brand and Generic Formula: Both brand and generic medications are capped at AWP + $5.00.
• Lesser-Of Audit Gate: Final reimbursement is the lowest of the state fee schedule amount, the pharmacy's submitted U&C charge, or a contracted network rate.
• WAC Alternative: When a verified AWP is unavailable, the pricing calculation uses 100% of WAC + $5.00.

Sources: South Carolina Workers' Compensation Commission Medical Services Provider Manual (MSPM) Section 10, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Direct Care

• Yes: South Carolina follows an employer-choice model. The employer or insurance carrier generally selects the treating physician and designated pharmacy fulfillment channels.

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 follows an open formulary structure with PBM controls for generic substitution and topical quantity limits.

Source: S.C. Code Ann. 42-15-60 / Workers' Compensation Commission

OTC Restrictions

• Prescription Requirement: OTC or non-legend medications are not reimbursable unless supported by a valid prescription or clinical order from the authorized treating physician.
• Electronic NCPDP Billing: Approved OTC prescriptions must be transmitted through standard NCPDP transactions rather than cash receipts or handwritten records.
• Pricing Limit: Reimbursement is limited to AWP + $5.00 or the pharmacy's submitted U&C price, whichever is lower.

Sources: Advisory Notice - SC Workers' Compensation Commission Medical Services Provider Manual Section 1, South Carolina Workers' Compensation Commission MSPM

Topical Restrictions

• Standard Pricing: Non-compounded topical medications are reimbursed at up to 100% of AWP + $5.00.
• Original Manufacturer NDC: Bill review systems may remove repackager or private-label NDCs and reference the original manufacturer's pricing data.
• Quantity Limits: High-cost topical medications and transdermal patches are subject to automated quantity and utilization controls.

Sources: Advisory Notice - SC Workers' Compensation Commission Medical Services Provider Manual Pharmacy Guidelines, Enlyte South Carolina Fee Schedule Resource Portal

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must be unbundled by ingredient, with each active component listed separately along with its quantity and NDC.
• Ingredient Pricing: Valid compound ingredients are reimbursed at 100% of published AWP. Components without valid NDCs are not reimbursable.
• Single Dispensing Fee: A single $5.00 dispensing fee applies to the compound transaction. Multiple professional handling fees cannot be stacked.
• Prior Authorization: Compounds are excluded from the standard formulary process and require pre-approved authorization before processing.

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

Timelines

• Billing Submission Deadline: Licensed retail pharmacies must submit properly coded bills within 365 calendar days of dispensing.
• Payer Payment Window: The carrier, self-insured employer, or third-party administrator has 30 calendar days after receiving a properly documented bill to pay or formally deny the charge.
• Employee Hold-Harmless: Retail pharmacies and collection entities cannot balance-bill an injured worker for an accepted workers' compensation claim.
• Hearing Appeal: A pharmacy disputing a payment reduction or denial must file an Application for Hearing (Form 58) with the Medical Services Division within 90 days of receiving the adverse remittance advice.

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

Pricing Source

• Red Book Master AWP Database

Sources: South Carolina Code of Laws Title 42, South Carolina Workers' Compensation Commission Official Administrative Directories

State Fee Schedule

• Usual and Customary Pricing: South Dakota does not apply percentage-based AWP formulas to outpatient retail prescriptions.
• Cost Ceiling: Brand and generic prescriptions are reimbursed at up to 100% of the pharmacy's submitted U&C charge.
• Community Value Standard: The submitted U&C amount must reflect the pharmacy's customary charge in the local market, regardless of payer.
• Lesser-Of Audit Gate: Final reimbursement is limited to the lower of the submitted U&C amount or a contracted network rate.

Sources: Administrative Rules of South Dakota (ARSD) 47:03:05:01, ARSD 47:03:05:14 (Reimbursement for Drugs), South Dakota Department of Labor and Regulation Workers' Compensation Division

Direct Care

• Yes: South Dakota follows an employee-choice framework for initial medical care. The injured worker may select the initial treating medical practitioner or licensed pharmacy.

Sources: South Dakota Codified Laws (SDCL) 62-4-43, South Dakota Department of Labor and Regulation Division of Labor and Management

Pre-Authorization

• No: South Dakota uses an open formulary model, with individual insurers applying utilization controls for specialty medications and other restricted drugs.

Source: S.D. Codified Laws 62-4-1 / Department of Labor

OTC Restrictions

• Prescription Requirement: OTC or non-legend medications are not reimbursable unless supported by a valid prescription or clinical order from the authorized treating physician.
• Electronic NCPDP Billing: Prescribed OTC medications must be submitted through standard NCPDP transactions rather than cash receipts or paper logs.
• U&C Pricing Limit: Approved OTC prescriptions are reimbursed at up to 100% of the pharmacy's submitted U&C price or the applicable contracted network rate, whichever is lower.

Sources: Administrative Rules of South Dakota (ARSD) 47:03:05:14, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Pricing: Non-compounded topical medications are reimbursed at up to 100% of the pharmacy's submitted U&C price or the applicable contracted network rate.
• Quantity Limits: High-cost topical medications and transdermal patches are subject to automated quantity and utilization controls.

Sources: Administrative Rules of South Dakota (ARSD) 47:03:05:14, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must be unbundled by ingredient, with each active component listed separately along with its quantity and NDC.
• U&C Pricing: Each validated compound ingredient is priced at up to 100% of its community U&C value or the applicable contracted network rate.
• Prior Authorization: Compounds are excluded from the standard formulary process and require pre-approved authorization before processing.

Sources: Administrative Rules of South Dakota (ARSD) 47:03:05:14, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Timelines

• Billing Submission Deadline: Licensed retail pharmacies must submit properly coded bills within 365 calendar days of dispensing.
• Payer Action: The insurance carrier or self-insured employer must act on a properly documented bill by issuing payment or formally denying the charge under applicable state processing rules.
• Employee Hold-Harmless: Providers cannot charge an injured worker amounts that exceed applicable maximum reimbursement limits during an active workers' compensation dispute.
• Dispute Resolution: Providers must first complete the insurer's internal dispute process. If the dispute remains unresolved after 30 calendar days, the provider may petition the department for a formal hearing within 30 calendar days of written notice of the insurer's final decision.

Sources: Administrative Rules of South Dakota (ARSD) 47:03:05:05, ARSD 47:03:05:06 (Dispute Resolution)

Pricing Source

• Pharmacy Submitted Community Value Registers and PBM Contracted Tiers

State Fee Schedule

• AWP-Based Pricing: Retail brand-name and generic prescriptions are priced using the Average Wholesale Price (AWP) effective on the date of dispensing.
• Brand and Generic Formula: Both single-source brand and multi-source generic drugs are reimbursed at AWP + $5.10.
• Original Manufacturer NDC Requirement: The original manufacturer's NDC must be used to determine the applicable AWP.
• Missing NDC Rule: If the original manufacturer's NDC is not reported, reimbursement is based on the AWP of the lowest-priced therapeutically equivalent drug on a per-unit basis.
• Lesser-of Payment Rule: Final reimbursement is the lesser of the provider's usual charge, a negotiated or contracted amount, or the applicable fee schedule amount of AWP + $5.10.

Sources: Tennessee Compilation of Rules and Regulations (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 for medical treatment. Under T.C.A. 50-6-204, the employer must provide a written panel of at least three independent physicians, and the injured worker must select the treating physician from that panel.

Sources: Tennessee Code Annotated (T.C.A.) Section 50-6-204, Tenn. Comp. R. & Regs. 0800-02-18-.12, Tennessee Bureau of Workers' Compensation Rules for Medical Payments

Pre-Authorization

• Yes: Tennessee uses the closed ODG Drug Formulary. The 2026 Medical Fee Schedule establishes the applicable AWP data hierarchy, with Medi-Span Price Alert identified as the primary pricing source.

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

OTC Restrictions

• Prescription Requirement: OTC or non-legend drugs are not reimbursable unless supported by a valid, signed prescription or clinical order from the authorized treating physician.
• Retail Pricing: When prescribed, OTC drugs are reimbursed at the pharmacy's usual retail price.
• No Filling Fee: OTC drugs are not eligible for a separate filling fee, making the reimbursable filling fee $0.00.

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

Topical Restrictions

• Standard Pricing: Non-compounded topical prescriptions, including creams, ointments, gels, transdermal products, and patches, are reimbursed at AWP + $5.10.
• Topical Compound Cap: Prescription topical compounds are subject to a maximum reimbursement of $240.00 for a 30-day supply.
• Prorated Supply: Topical compounds prescribed for periods other than 30 days are prorated based on the $240.00 maximum.
• FDA Approval: Each ingredient used in a topical compound must be FDA-approved for topical use to qualify for reimbursement.

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

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must be itemized by ingredient. Bills for compounded or repackaged products must include the original manufacturer's FDA-registered NDC or the authorized distributor's stock-package NDC.
• Ingredient Pricing: Each compound ingredient is priced separately using the manufacturer's current AWP on the date of dispensing.
• Original NDC Requirement: Repackaged or compounded NDCs cannot be used as the original manufacturer's NDC for pricing.
• Single Filling Fee: Only one $5.10 filling fee may be applied to the entire compound transaction.

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

Timelines

• Billing Deadline: Retail pharmacies must submit properly coded electronic bills within 365 days of dispensing. Late submissions may be administratively denied.
• Payer Payment Window: Insurers, third-party administrators, and self-insured employers generally have 30 days from receipt of an undisputed bill to issue payment.
• Employee Protection: Providers must bill the workers' compensation payer and may not balance-bill the injured employee for covered services.
• Medical Dispute Appeal: Pharmacies disputing a payment reduction or denial may file Form C-42 (Medical Dispute Form) with the Bureau's Medical Fee Dispute Section within 90 days of receiving the adverse remittance advice.

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

Sources: Tenn. Comp. R. & Regs. 0800-02-18-.12, Tennessee Department of Labor and Workforce Development

State Fee Schedule

• AWP-Based Pricing: Retail brand-name and generic prescriptions are priced using the AWP effective on the date of dispensing.
• Brand Formula: Single-source brand drugs are reimbursed at AWP × 1.09 + $4.00.
• Generic Formula: Multi-source generic drugs are reimbursed at AWP × 1.25 + $4.00.
• Lesser-of Payment Rule: Final reimbursement is the lesser of the applicable brand or generic fee schedule amount or the provider's actual billed charge.
• Fair and Reasonable Fallback: When a drug price cannot be determined under the standard AWP methodology, reimbursement defaults to a fair and reasonable amount under Texas Labor Code 408.028(f).

Sources: 28 Texas Administrative Code (TAC) 134.503(a), 28 TAC 134.503(c), 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 at a compliant contracted rate rather than the general fee guideline.

Sources: Texas Insurance Code Chapter 1305, 28 TAC 134.503(f), Texas Labor Code 408.0281

Pre-Authorization

• Yes: Texas uses the closed ODG Appendix A Drug Formulary. "Y" status medications may process automatically, while "N" status medications and compounds require prospective prior authorization.

Source: Texas Labor Code 408.028, Texas Division of Workers' Compensation

OTC Restrictions

• Prescription Requirement: OTC and non-prescription drugs are not reimbursable unless supported by a valid written prescription from the authorized treating physician.
• Retail Price Rule: Reimbursement for prescribed OTC drugs is based on the retail price of the lowest reasonably available package quantity needed to fill the prescription.
• No Dispensing Fee: OTC medications do not qualify for a separate professional dispensing fee, resulting in a $0.00 dispensing fee.

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

Topical Restrictions

• Standard Pricing: Non-compounded topical prescriptions are reimbursed under the applicable brand or generic formula: AWP × 1.25 + $4.00 for generic drugs or AWP × 1.09 + $4.00 for brand drugs.
• Quantity Limits: High-cost topical medications and transdermal patches are subject to quantity controls and may be reduced or rejected when they exceed the permitted 90-day supply.

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

Compound Restrictions

• Ingredient-Level Billing: Compounds must identify each drug included in the compound and calculate the charge for each ingredient separately.
• Ingredient Pricing: Each ingredient is priced using the applicable brand or generic AWP formula.
• Invalid NDC: Ingredients with missing or unrecognized NDCs are not reimbursable and may be reduced to $0.00.
• Compounding Fee: A single $15.00 compounding fee may be added to the calculated ingredient total.
• Prior Authorization: Compounds are treated as Status N drugs and require prospective prior authorization before processing.

Sources: 28 TAC 134.502(d), 28 TAC 134.503(c), Texas Department of Insurance Division of Workers' Compensation Pharmacy Rules

Timelines

• Billing Deadline: Retail pharmacies must submit properly coded bills within 95 days of the date of service. Late bills may be administratively denied.
• Payer Payment Window: Insurers and third-party administrators generally have 45 days from receipt of a clean, undisputed bill to pay or deny the claim.
• Employee Protection: Under Texas Labor Code 413.042, injured workers may not be balance-billed for covered pharmacy or medical services.
• Fee Dispute Appeal: Pharmacies disputing a payment reduction or denial may file DWC Form-060 for Medical Fee Dispute Resolution within 365 days of the date of service.

Sources: 28 TAC 133.20, 28 TAC 133.307, Texas Labor Code 413.042

Pricing Source

• Red Book and Medi-Span AWP Databases

Sources: 28 TAC Chapter 134 Subchapter F, Texas Department of Insurance Official Administrative Directories

State Fee Schedule

• Reasonable Fee Standard: Retail brand-name and generic prescriptions are not subject to a mandatory AWP percentage formula.
• Maximum Allowable Rate: Reimbursement is limited to the lesser of a fair and reasonable fee or the provider's standard charge.
• Community Pricing Review: Charges are reviewed against prevailing community prices for the same products or services.
• Lesser-of Payment Rule: Final payment is the lowest of the reasonable fee, the provider's public charge, or a contracted network rate.

Sources: Utah Code Annotated Section 34A-2-407, Utah Administrative Code Rule R612-300-1, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Direct Care

• Yes: Utah permits self-insured employers and insurers to establish managed care or Preferred Provider Programs (PPP) under applicable state rules.

Sources: Utah Administrative Code Rules R612-300-1 and R612-300-2, Utah Labor Commission Employer and Insurer Guidelines

Pre-Authorization

• Yes: Utah follows the ODG Drug Formulary. Point-of-sale systems may require prior authorization for nonpreferred or "N" status medications.

Source: Utah Code 34A-2-407, Utah Labor Commission Rules

OTC Restrictions

• Prescription Requirement: OTC or non-legend drugs are not reimbursable unless supported by a valid, signed prescription or clinical order from the authorized treating physician.
• Electronic Billing: Prescribed OTC medications must be submitted electronically through standard NCPDP transactions.
• U&C Pricing: Reimbursement is limited to the lesser of the pharmacy's submitted U&C price or a contracted network rate.

Sources: Utah Code Annotated Section 58-17b-102, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Pricing: Non-compounded topical medications are reimbursed under the state's standard pricing rules, limited to the pharmacy's U&C price or contracted network rate.
• Quantity Limits: High-cost topical medications and transdermal patches may be subject to quantity and days-supply limits.

Sources: Utah Labor Commission Medical Fee Standard, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must be itemized by ingredient, including the quantity and applicable NDC for each component.
• Ingredient Pricing: Each ingredient is evaluated at its community value or applicable contracted network rate.
• Prior Authorization: Compounds may be blocked at point of sale until required prior authorization is obtained.

Sources: Utah Code Annotated Section 58-17b-611, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Timelines

• Billing Deadline: Retail pharmacies must submit properly coded bills within 365 days of dispensing under applicable Utah billing rules.
• Payer Payment Window: Insurers, self-insured employers, and third-party administrators generally have 45 days from receipt of an undisputed bill to pay or deny the claim.
• Employee Protection: Injured workers are protected from balance-billing during active workers' compensation billing disputes.
• Fee Dispute Appeal: Providers may file an Application for Hearing with the Utah Labor Commission, Division of Industrial Accidents, within 1 year of the final adverse notice.

Sources: Utah Administrative Code Rule R612-300-7, Utah Code Annotated Section 34A-2-407

Pricing Source

• Pharmacy Community Value Registers and PBM Contracted Tiers

Sources: Utah Code Annotated Title 34A Chapter 2, Utah Labor Commission Official Administrative Directories

State Fee Schedule

• AWP-Based Pricing: Retail brand-name and generic prescriptions are priced using the AWP effective on the date of dispensing.
• Brand and Generic Formula: Both brand and generic drugs are reimbursed at AWP + $3.15.
• Lesser-of Payment Rule: Final reimbursement is limited to the lesser of the calculated fee schedule amount or the provider's actual billed charge.
• Standard Billed Charge: The pharmacy's billed amount should reflect its typical charge for the same medication or service across payers.

Sources: Vermont Department of Labor Workers' Compensation Rules, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Direct Care

• No: Vermont follows an employee-choice framework. Under 21 V.S.A. 640(a), an injured worker generally has the right to select the treating medical provider or pharmacy.

Sources: Vermont Statutes Annotated Title 21 Section 640(a), Vermont Department of Labor Guidelines

Pre-Authorization

• No: Vermont follows an open formulary framework, with retail prescriptions generally subject to the AWP + $3.15 pricing formula.

Source: Vt. Stat. Ann. tit. 21, Section 640, Vermont Department of Labor

OTC Restrictions

• Prescription Requirement: OTC and non-prescription drugs are not reimbursable unless supported by a valid, signed prescription or clinical order from the authorized treating physician.
• Electronic Billing: Prescribed OTC medications must be submitted electronically through standard NCPDP transactions.
• Pricing Limit: Reimbursement is limited to the lesser of AWP + $3.15 or the pharmacy's actual billed charge.

Sources: Vermont Department of Labor Workers' Compensation Rules, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Pricing: Non-compounded topical prescriptions are reimbursed at AWP + $3.15.
• Topical Compound Cap: Topical compounds are limited to the lesser of $200.00 for a 30-day supply, prorated as needed, or the amount allowed under the general fee schedule.
• Quantity Limits: High-cost topical medications and patches may be subject to quantity and days-supply limits.

Sources: Vermont Department of Labor Workers' Compensation Rules, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Compound Restrictions

• Ingredient-Level Billing: Compounded prescriptions must be itemized by ingredient, including quantity and NDC.
• Ingredient Pricing: Each component is reimbursed based on its applicable AWP.
• Invalid NDC: Ingredients with missing or invalid NDCs are not reimbursable and may be reduced to $0.00.
• Single Dispensing Fee: Only one $3.15 dispensing fee applies to the compound transaction.

Sources: Vermont Department of Labor Workers' Compensation Rules, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Timelines

• Billing Deadline: Pharmacies must submit properly coded bills within the applicable Vermont billing timeframe. Late submissions may be subject to administrative denial.
• Payer Payment Window: Under Rule 40.010, employers and insurers generally have 30 days after receiving the bill and supporting documentation to pay the provider or apply the applicable maximum payment.
• Employee Protection: Under 21 V.S.A. 640(a), an employee is not responsible for payment of compensable work-related medical treatment.
• Fee Dispute Appeal: Pharmacies disputing a payment reduction or denial may appeal to the Vermont Department of Labor within the applicable regulatory timeframe.

Sources: Vermont Statutes Annotated Title 21 Section 640(a), Vermont Department of Labor Rule 40.010

Pricing Source

• Red Book and Medi-Span AWP Master Database

Sources: Vermont Rule 40.000, Vermont Department of Labor Official Administrative Directories

State Fee Schedule

• Pharmacy Fee Schedule Exclusion: Traditional retail pharmacy prescriptions are excluded from Virginia's automated Medical Fee Schedule.
• Community Rate Standard: Brand-name and generic prescriptions are limited to 100% of the prevailing community rate.
• Statutory Liability Limit: Under Va. Code 65.2-605, employer liability for necessary medical and pharmaceutical services is limited to charges prevailing in the same community for comparable treatment.
• Rebuttable Presumption: A pharmacy's submitted bill is treated as prima facie evidence that its charges are reasonable. The employer or carrier may rebut this presumption with evidence of excessive charges from other pharmacies in the community.

Sources: Code of Virginia Section 65.2-605, Rules of the Virginia Workers' Compensation Commission Rule 14, Ceres Marine Terminals v. Armstrong, 59 Va. App. 694 (2012)

Direct Care

• No: Virginia follows an employer-choice framework. Under Va. Code 65.2-603, the employer must provide a written panel of at least three independent physicians, from which the injured worker selects the treating physician.

Source: Va. Code 65.2-603

Pre-Authorization

• No: Retail pharmacy prescriptions are excluded from the automated fee schedule and generally use the prevailing community rate. PBMs may apply generic substitution requirements.

Source: Va. Code Ann. 65.2-603, Virginia Workers' Compensation Commission

OTC Restrictions

• Prescription Requirement: OTC and non-prescription drugs are not reimbursable unless supported by a valid, signed prescription or clinical order from the authorized panel physician.
• Community Pricing: Prescribed OTC medications are reimbursed at the prevailing community rate or a lower contracted network rate.
• No Filling Fee: OTC items do not qualify for a separate professional filling or handling fee, resulting in a $0.00 fee.

Sources: Code of Virginia Section 65.2-605, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Pricing: Non-compounded topical medications are reimbursed at the prevailing community rate for the specific product.
• Quantity Limits: High-cost topical medications and transdermal patches may be subject to quantity and days-supply limitations.

Sources: Code of Virginia Section 65.2-605, Ford Richardson Law Virginia Cost-Containment Protocols

Compound Restrictions

• Ingredient-Level Billing: Compounds must be itemized by ingredient, including quantity and NDC.
• Community Rate Pricing: Each validated compound ingredient is evaluated against the prevailing community rate for the applicable drug or chemical.
• Invalid NDC: Ingredients with invalid or unrecognized NDCs may be reduced to $0.00.
• Prior Authorization: Compounds may require prospective authorization before point-of-sale processing.

Sources: Code of Virginia Section 65.2-605, Rules of the Virginia Workers' Compensation Commission Rule 14, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Timelines

• Billing Dispute Deadline: Providers disputing insufficient payment must generally submit the claim within 1 year from the date the last payment was received from the carrier.
• Injury Filing Deadline: Work-related injury claims generally must be filed within 2 years of the accident under Va. Code 65.2-601.
• Employee Protection: Injured workers are protected from balance-billing for covered workers' compensation pharmacy services.
• Administrative Appeal: Pharmacies disputing a payment reduction or denial may request an Administrative Review and Determination from the Commission. A request for a formal hearing must generally be filed within 30 days of the administrative decision.

Sources: Code of Virginia Section 65.2-601, Virginia Workers' Compensation Commission Administrative Review Rules, Ford Richardson Law Virginia Cost-Containment Protocols

Pricing Source

• Geographic Community Value Registers and Rule 14 Regional Maps

Sources: Code of Virginia Title 65.2, Rules of the Virginia Workers' Compensation Commission, Virginia Workers' Compensation Commission Official Administrative Directories

State Fee Schedule

• Brand-Name Retail Cost Formula: Brand-name prescriptions filled at a licensed retail pharmacy are reimbursed at AWP × 0.90 + a $4.50 professional fee.
• Generic Retail Cost Formula: Multi-source generic prescriptions are reimbursed at AWP × 0.50 + a $4.50 professional fee.
• Lesser-of Payment Rule: Final reimbursement is limited to the lowest of the applicable fee schedule amount, the pharmacy's usual public charge, or a lower contracted network rate.
• Public Pricing Limit: A pharmacy cannot charge workers' compensation more than its standard charge to cash-paying customers or the general public for the same prescription.

Sources: Washington Administrative Code (WAC) 296-20-010, WAC 296-20-01002, 2026 Washington L&I Medical Aid Rules and Fee Schedules (MARFS) Chapter 19 (Pharmacy)

Direct Care

• No: Washington operates as a monopolistic State Fund jurisdiction, with L&I managing claims and establishing rules for permitted self-insured employers. Under WAC 296-20-015, injured workers may initially choose any attending physician who participates in the L&I Medical Provider Network.

Sources: Revised Code of Washington (RCW) 51.04.030, WAC 296-20-015, 2026 Washington L&I MARFS Chapter 19 (Pharmacy)

Pre-Authorization

• Yes: Washington uses an L&I-administered formulary with a Preferred Drug List (PDL). Nonpreferred medications require prospective authorization.

Source: Wash. Rev. Code 51.36.010 / 2026 Senate Bill 5847

OTC Restrictions

• Prescription Requirement: OTC products are not reimbursable unless accompanied by a valid prescription from an authorized network provider.
• Oral OTC Pricing: Prescribed oral OTC medications are reimbursed under the generic formula of AWP × 0.50 + $4.50 professional fee.
• Non-Oral OTC Pricing: Non-oral OTC products, including certain medical devices and retail kits, are reimbursed using an acquisition-based formula with a maximum 40% margin over actual wholesale cost.

Sources: RCW 82.08.0281, 2026 Washington L&I MARFS Chapter 19 (Pharmacy), Washington State Department of Labor & Industries Pharmacy Billing Guide

Topical Restrictions

• Standard Topical Pricing: Standalone prescription topicals, including creams, transdermal ointments, and gels, follow the standard AWP formula at 0.90 for brand products or 0.50 for generic products, plus the $4.50 professional fee.
• Quantity Limits: High-cost topical medications and specialized patches are subject to automated quantity limits. Claims exceeding the allowed units or 30-day supply may be rejected or reduced.

Sources: 2026 Washington L&I MARFS Chapter 19 (Pharmacy), Washington State Department of Labor & Industries Outpatient Formulary Limits

Compound Restrictions

• Component-Level Billing: Compounded prescriptions must be itemized by ingredient. Each active ingredient must be separately identified with its metric quantity and NDC.
• Ingredient Pricing: Each compound ingredient is priced using its applicable AWP. Brand ingredients use AWP × 0.90, while generic ingredients use AWP × 0.50.
• Compounding Labor Fee: In addition to ingredient costs and the $4.50 professional fee, pharmacies may receive a compounding labor fee of up to $4.00 per 15 minutes of documented preparation time.
• Prior Authorization: Compounds require prospective authorization from L&I or the applicable self-insured carrier before dispensing.

Sources: 2026 Washington L&I MARFS Chapter 19 (Pharmacy), Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Timelines

• Billing Submission Deadline: Pharmacies must submit properly coded electronic bills within 1 year (365 calendar days) of dispensing under WAC 296-20-125.
• Payment Window: Self-insured employers or their third-party administrators have 60 calendar days after receiving an undisputed bill to pay or formally deny the claim.
• Employee Hold-Harmless: Providers and pharmacies may not balance-bill an injured worker for services related to an accepted workers' compensation claim.
• Appeals: Pharmacies disputing a payment reduction or denial must submit a written protest to L&I Provider Appeals or appeal to the Board of Industrial Insurance Appeals (BIIA) within 60 calendar days of receiving the adverse order.

Sources: RCW 51.04.030, RCW 51.32.190, WAC 296-20-010, WAC 296-20-125, Washington BIIA Rules of Practice and Procedure

Pricing Source

• L&I Pharmacy Fee Systems & Nationally Recognized AWP Databases: RED BOOK / Medi-Span

Sources: RCW Title 51, WAC Title 296, Washington State L&I Official Administrative Directories

State Fee Schedule

• Non-Formulaic Pricing: Retail brand and generic prescriptions are not subject to mandatory percentage-based AWP formulas.
• Usual and Customary Limit: Brand and generic medications are reimbursed at up to 100% of the provider's usual and customary (U&C) charge to the public.
• Community Pricing Standard: The submitted U&C amount must reflect the pharmacy's normal charge for the same medication to the general public.
• Lesser-of Payment Rule: Final reimbursement is limited to the lowest of the reasonable fee, public charge, or contracted network rate.

Sources: District of Columbia Department of Employment Services (DOES) Office of Workers' Compensation, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Direct Care

• No: Washington, D.C. follows an employee-choice framework. The injured worker may initially select an attending physician or licensed pharmacy to manage the treatment path.

Sources: District of Columbia Official Code Section 32-1507, District of Columbia Department of Employment Services (DOES)

Pre-Authorization

• No: The District does not use a state-mandated pharmacy fee schedule or closed formulary. Retail pharmacy items are generally reimbursed at 100% of the provider's U&C charge.

Source: D.C. Official Code 32-1507 / DOES Guidance

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless accompanied by a valid prescription or formal clinical order from the authorized treating physician.
• Electronic Billing: Prescribed OTC medications must be submitted through standard NCPDP pharmacy transactions rather than manual receipts or paper logs.
• U&C Pricing: Reimbursable OTC medications are limited to the lower of the submitted U&C price or contracted network rate.

Sources: District of Columbia Department of Employment Services (DOES) Medical Guidelines, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Topical Pricing: Non-compounded topical medications are reimbursed at up to 100% of the pharmacy's U&C price or the applicable contracted network rate.
• Quantity Limits: High-cost topical medications and specialized patches are subject to automated quantity and days' supply limits.

Sources: District of Columbia Municipal Regulations (DCMR) Title 7, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Compound Restrictions

• Component-Level Billing: Compounded medications must be itemized by individual ingredient, including the metric quantity and NDC.
• Ingredient Pricing: Each component is reimbursed at its standard U&C value or applicable contracted network rate.
• Prior Authorization: Compounds require authorization before the transaction can be processed through the retail pharmacy system.

Sources: District of Columbia Department of Employment Services (DOES), Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Timelines

• Billing Submission Deadline: Pharmacies must submit properly coded electronic bills within 1 year (365 calendar days) of dispensing.
• Payment Window: Insurers, self-insured employers, and third-party administrators have 30 calendar days after receiving an undisputed bill to pay or formally deny the claim.
• Employee Hold-Harmless: Injured workers may not be balance-billed for covered pharmacy services during a billing dispute.
• Appeals: Pharmacies disputing a payment reduction or denial must submit a formal Request for Utilization Review to the DOES Office of Workers' Compensation within 30 days of receiving the adverse remittance advice.

Sources: District of Columbia Official Code Section 32-1507, DOES Office of Workers' Compensation Administrative Rules

Pricing Source

• Pharmacy Submitted Community Value Registers & PBM Contracted Tiers

Sources: D.C. Official Code Title 32, DOES Office of Workers' Compensation Official Directories

State Fee Schedule

• NADAC Pricing Standard: Retail brand and generic prescriptions are priced using the National Average Drug Acquisition Cost (NADAC) in effect on the dispensing date.
• Brand and Generic Formula: Both brand and generic medications are reimbursed at NADAC + $10.49 professional dispensing fee.
• NADAC Fallback: When a drug does not have an established NADAC price, reimbursement defaults to WAC + $10.49.
• Office Dispensing Exception: Physicians dispensing medication from office stock under a verified emergency exception do not receive the $10.49 dispensing fee.
• Lesser-of Payment Rule: Final reimbursement is limited to the lower of the pharmacy's U&C charge or contracted network rate, provided the amount meets the applicable NADAC/WAC pricing requirement.

Sources: West Virginia Code Section 23-4-3, West Virginia Code of State Rules (W.V.C.S.R.) 85-20-14, West Virginia Offices of the Insurance Commissioner PBM NADAC Enforcement Guides, West Virginia House Bill 5430 (2026 Amendments)

Direct Care

• Yes: West Virginia permits employers and private insurers to establish approved Managed Health Care Plans (MHCPs). When an approved plan is in place, injured workers must use participating providers and pharmacies within the designated network.

Sources: West Virginia Code Section 23-4-3, W.V.C.S.R. 85-21-3, West Virginia House Bill 5430 (2026 Acts)

Pre-Authorization

• No: Retail pharmacy claims follow the state pricing standard of NADAC plus the $10.49 dispensing fee.

Source: W. Va. Code 23-4-3 / Insurance Commissioner Rules

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless accompanied by a valid prescription from the authorized treating physician.
• Electronic Billing: Prescribed OTC medications must be submitted through standard NCPDP pharmacy transactions.
• Storefront Pricing: Reimbursable OTC medications are limited to the lower of the retail marketplace price or contracted network rate.

Sources: West Virginia Code Section 23-4-3, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Topical Pricing: Standalone topical medications follow the applicable NADAC/WAC pricing formula plus the $10.49 professional fee.
• 30-Day Supply Cap: Standard topical preparations are limited to a maximum reimbursement of $80.00 per 30-day supply.
• Transdermal Patch Cap: Manufactured prescription patches are limited to $60.00 per 30-day supply, prorated as needed.

Sources: W.V.C.S.R. 85-20-14, West Virginia Offices of the Insurance Commissioner Guidelines, myMatrixx Regulatory Update 2026

Compound Restrictions

• Component-Level Billing: Compounded prescriptions must be itemized by ingredient, including metric quantity and NDC.
• Ingredient Pricing: Each ingredient is evaluated under the applicable NADAC or WAC pricing formula. Ingredients with missing or invalid NDCs are not reimbursed.
• Single Dispensing Fee: Only one $10.49 dispensing fee may be applied to the entire compound transaction.
• Compound Authorization: Compounds exceeding $80.00 require prospective prior authorization and supporting medical documentation.

Sources: W.V.C.S.R. 85-20-14, West Virginia Board of Pharmacy Compounding Standards, myMatrixx Regulatory Update 2026

Timelines

• Billing Submission Deadline: Pharmacies and clinics must submit properly coded bills within 11 months (335 calendar days) of dispensing.
• Payment Window: Insurers, self-insured employers, and third-party administrators have 30 calendar days after receiving an undisputed bill to issue payment.
• Employee Hold-Harmless: Providers and pharmacies may not balance-bill injured workers for covered claims.
• Reconsideration and Dispute: Pharmacies have 60 days to submit a reconsideration request. Payers have 60 days to respond, followed by an additional 60-day period for providers to file a formal dispute resolution petition with the Insurance Commissioner.

Sources: West Virginia Code Section 23-4-3, W.V.C.S.R. Title 85, West Virginia Offices of the Insurance Commissioner Dispute Resolution Procedures

Pricing Source

• CMS Weekly National Average Drug Acquisition Cost (NADAC) Survey Reports

Sources: West Virginia Code Chapter 23, W.V.C.S.R. Title 85, West Virginia Offices of the Insurance Commissioner Official Administrative Directories

State Fee Schedule

• Statutory Pricing Ceiling: Retail prescription medications are subject to the requirements of Wis. Stat. 102.425(3)(a).
• Brand and Generic Formula: Both brand and generic medications are reimbursed at AWP + $3.00.
• Lesser-of Payment Rule: Final reimbursement is limited to the lowest of the fee schedule amount, the pharmacy's U&C price, or a contracted network rate.
• Invoice Itemization: Pharmacy invoices must separately identify the drug price and dispensing fee.
• NDC Requirement: Retail pharmacy bills must include the prescription's NDC as listed in the FDA National Drug Code Directory.

Sources: Wis. Stat. Section 102.425(3)(a), Wis. Stat. Section 102.425(3)(c), Wisconsin DWD Worker's Compensation Division

Direct Care

• Yes: Wisconsin follows an employee-choice framework. Under Wis. Stat. 102.42(2), an injured worker may initially select a licensed physician or associated pharmacy.

Sources: Wis. Stat. Section 102.42(2), Wis. Stat. Section 102.425(3)(a), Wisconsin DWD Employer and Insurer Guidelines

Pre-Authorization

• No: Retail pharmacy transactions follow the statutory fee schedule of AWP + $3.00.

Source: Wis. Stat. 102.425 / Department of Workforce Development

OTC Restrictions

• Prescription Requirement: OTC medications are not reimbursable unless accompanied by a valid written prescription or formal clinical order.
• Public Pricing Limit: Employer or insurer liability for nonprescription drugs is limited to the pharmacy's U&C charge to the general public.
• No Dispensing Fee: OTC products do not qualify for a professional dispensing fee.

Sources: Wis. Stat. Section 102.425(5), Wisconsin Department of Workforce Development Rules

Topical Restrictions

• Standard Topical Pricing: Standalone topical medications follow the standard AWP + $3.00 pricing formula.
• Quantity Limits: High-cost topicals and specialized patches are subject to automated quantity and days' supply limits.

Sources: Wis. Stat. Section 102.425(3)(a), Wisconsin DWD Medical Practice Standards

Compound Restrictions

• Component-Level Billing: Compounded prescriptions must be itemized by individual ingredient, including metric quantity and NDC.
• Ingredient Pricing: Each ingredient is reimbursed at 100% of its published AWP. Ingredients with missing or invalid NDCs are not reimbursed.
• Single Dispensing Fee: Only one $3.00 professional dispensing fee may be applied to the complete compound transaction.

Sources: Wis. Stat. Section 102.425(3)(a), Wisconsin DWD Administrative Rules

Timelines

• Payment and Dispute Notice: If an employer or insurer disputes a prescription drug charge, written notice must be provided to the pharmacist within 30 days of receiving a completed bill.
• Employee Hold-Harmless: Once written notice of a dispute is provided, the pharmacist may not collect the disputed amount from the employee.
• Out-of-Pocket Reimbursement: Employers or insurers are responsible for reimbursing injured employees for valid prescription drug expenses paid out of pocket.
• Administrative Dispute: Pharmacies disputing a payment reduction or denial must submit the matter to the DWD Worker's Compensation Division for formal administrative review.

Sources: Wis. Stat. Section 102.425(4m)(b), Wis. Stat. Section 102.425(3)(a), Wis. Stat. Section 102.425(4m)(c)

Pricing Source

• Nationally Recognized Database Registers: RED BOOK / Medi-Span AWP Databases

Sources: Wis. Stat. Section 102.425, Wisconsin Department of Workforce Development

State Fee Schedule

• Brand-Name Formula: Brand-name prescriptions are reimbursed at AWP × 0.90 + $5.00 professional filling fee.
• Generic Formula: Multi-source generic prescriptions are reimbursed at AWP × 0.90 + $5.00 professional filling fee.
• Lesser-of Payment Rule: Final reimbursement is limited to the lower of the applicable fee schedule amount or the pharmacy's U&C charge.
• Public Pricing Limit: The pharmacy's billed amount must reflect its typical cash or public charge for the same prescription.

Sources: Wyoming Department of Workforce Services (DWS) Workers' Compensation Rules Chapter 9, 9-6, 053-0021-10 Wyoming Administrative Code R. 10-25, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Direct Care

• No: Wyoming operates as a monopolistic State Fund jurisdiction, with DWS managing claims and medical coverage. Injured workers have the primary statutory right to select their initial treating provider.

Sources: Wyoming Statutes (W.S.) 27-14-401, Wyoming Department of Workforce Services (DWS) Injured Worker Guidelines, 2026 Wyoming Workers' Compensation Chapter 9 Rules

Pre-Authorization

• No: Retail pharmacy bills are capped at AWP × 0.90 + $5.00. Point-of-sale systems may apply prospective holds to non-generic or high-cost medications.

Source: Wyo. Stat. Ann. 27-14-401 / DWS Chapter 9 Rules

OTC Restrictions

• Prescription Requirement: OTC products are not reimbursable unless accompanied by a valid prescription from the treating provider.
• U&C Pricing: Prescribed OTC medications are reimbursed at the lower of the pharmacy's submitted U&C price or a contracted network rate.
• No Filling Fee: OTC products do not qualify for a professional filling or administrative handling fee.

Sources: 053-10 Wyoming Administrative Code R. 10-25(a), Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Topical Restrictions

• Standard Topical Pricing: Standalone topical medications follow the standard AWP × 0.90 + $5.00 formula.
• Topical Compound Cap: Topical compounds are limited to the lesser of $200.00 per 30-day supply, prorated as needed, or the applicable compound reimbursement amount.
• Quantity Limits: High-cost topicals and specialized patches are subject to automated quantity and days' supply limits.

Sources: 053-9 Wyoming Administrative Code R. 9-7, Wyoming Workers' Compensation Chapter 10 Miscellaneous Medical Protocols, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Compound Restrictions

• Component-Level Billing: Compounded prescriptions must be itemized by ingredient, including metric quantity and NDC.
• Ingredient Pricing: Each ingredient is priced using the applicable AWP formula, with brand and generic components calculated at AWP × 0.90.
• Single Dispensing Fee: Only one $5.00 dispensing fee may be applied to the entire compound transaction.
• Prior Authorization: Compounds require prospective authorization before the pharmacy can process the transaction.

Sources: 053-9 Wyoming Administrative Code R. 9-7, Optum Pharmacy Resource Guide - Workers' Compensation March 2026

Timelines

• Billing Submission Deadline: Pharmacies must submit properly coded electronic bills within 1 year (365 calendar days) of dispensing.
• Employee Hold-Harmless: Injured workers may not be balance-billed for covered pharmacy services during an active billing dispute.
• Fee Disputes: Pharmacies disputing a payment reduction or denial must submit a formal written dispute to the Wyoming DWS Workers' Compensation Division within 30 days of the adverse notice.

Sources: Wyoming Statutes (W.S.) § 27-14-401, Wyoming Department of Workforce Services Rules, Regulations, and Fee Schedules

Pricing Source

• Nationally Recognized AWP Databases: RED BOOK / Medi-Span

Sources: Wyo. Code R. Agency 053, Subagency 0021, Chapters 9 and 10, Wyoming Department of Workforce Services Official Administrative Directories