Pharmacy Benefit Management

Topics	First Fill Program	Forms & Publications	Service Guide for Pharmacists
Pharmacy Overview	Sign Up Process	Prior Authorization Form (M3)	Quick Reference Sheet
US Script	Pharmacy Fee Schedule	Formulary/Product Resrictions	Brand Medication Prior Authorization Form (P2)
Plan Benefits	Generic Dispensing	Drug Quantity Limits	Relistor Prior Authorization Form (P3)
Plan Design		First Fill Product Restrictions	DAW1 Policy Statement
		Sample Narcotic Contract

Pharmacy Fee Schedule
All outpatient prescriptions must be submitted electronically to the pharmacy benefit management provider US Script. WSI does not directly reimburse injured workers for medication.

The pharmacy fee schedule is based on Firstdatabank’s Electronic Drug file wholesale acquisition price (WAC) for all national drug codes (NDC).

The pharmacy fee schedule for maximum allowable cost (MAC) is based on the most current MAC list provided by US Script, Inc.

WSI reimburses for prescribed brand name drugs at the WAC plus 8%, plus a single per item dispensing fee of $4.00.

WSI reimburses for generic drugs at the lesser of MAC plus 5% or WAC plus 8%, plus a single per item dispensing fee of $5.00.

WSI pays in full any charges submitted that are less than or equal to the maximum allowable fee.

Charges for Durable Medical Equipment (DME) or supply items (i.e. gauze, tape etc.) need to be submitted to WSI in paper format or electronically in the CMS 1500 format.