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Good Morning
7:08:01 AM CDT
Monday, April 21, 2014

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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 average wholesale pricing (AWP) 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 AWP minus 10%, plus a single per item dispensing fee of $4.00.

WSI reimburses for generic drugs at the lesser of MAC plus 5% or AWP minus 10%, 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.

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