Pharmacy Benefit Management
The pharmacy fee schedule is based on Wolters Kluwer Medicspan 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.
Pharmacy Fee Schedule for Compounded Prescriptions
WSI reimburses for compounded prescriptions at average wholesale price (AWP) minus 72%, plus a single item compounding fee based on the following level of effort (LOE) level:
|
Compound LOE
|
Value
|
Reimbursement
|
|
Level 1
|
11
|
$10.00
|
|
Level 2
|
12
|
$15.00
|
|
Level 3
|
13
|
$20.00
|
|
Level 4
|
14
|
$25.00
|
Level 1: Mixing liquids using graduated cyclinders.
Level 2: Triturate powder and mix by geometric dilution, mix creams, ointments, emulsions, and liquids by hand or by using unguator.
Level 3: Suppository mold, lollipop mold, and troche/mini-troche mold, dissolve powder using stirrer and hot plate, melt base on hot plate, burette and/or pH meter, making capsules using capsule filling machine.
Level 4: USP 797, sterile compounding using hood.
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