SECTION 42.115. Pharmaceutical Fee Guideline

(a) The maximum allowable charge for pharmaceuticals under the Pharmaceutical Fee Guideline for Services Rendered Under the Workers' Compensation Law is the lesser of:

(1) the provider's usual charge; or

(2) the fees established by the formulas for brand-name and generic pharmaceuticals as described in subsection (c) of this section.

(b) This section applies to the dispensing of all pharmaceuticals on and after February 1, 1991, excluding the inpatient health care facility setting.

(c) The formulas for establishing fair and reasonable fees and charges for brand-name and generic pharmaceuticals are:

(1) brand-name pharmaceutical formula: average wholesale price (AWP) times 1.09 plus $4.00;

(2) generic pharmaceutical formula: AWP times 1.38 plus $7.50.

(d) The AWP shall be determined with the monthly publication of Medispan. The publication that shall be used for the calculation shall be the same month that includes the date of service. When an AWP is changed during the month, the provider shall still use the AWP from the monthly publication. The two Medispan publications to be used are:

(1) Prescription Pricing Guide; or

(2) Generic Buying and Reimbursement Guide.

(e) When a generic pharmaceutical costs more than a brand-name pharmaceutical, according to the formulas described in subsection (c) of this section, the commission will consider the fair and reasonable price to be the brand-name equivalent, as calculated under subsection (c)(1) of this section.

(f) When there is no national drug code (NDC) number listed in the Medispan Generic Buying and Reimbursement Guide for a manufacturer, or when the provider fails to list the NDC number for each generic pharmaceutical on the bill submitted to the insurance carrier, the commission will determine the fair and reasonable reimbursement for generic pharmaceuticals by the following formula: generic equivalent average price (GEAP) times 1.38 plus $7.50.

Source Note: The provisions of this §42.115 adopted to be effective September 1, 1988, 13 TexReg 4131; amended to be effective February 5, 1991, 16 TexReg 372.