Fee Schedule

The pharmacy fee schedule is based on Wolters Kluwer Medispan Electronic Drug file wholesale acquisition price (WAC) for all national drug codes (NDC).

Generic Medication Fee Schedule

  • The lesser of maximum allowable cost (MAC) plus 5% or WAC plus 8%, plus a single per item dispensing fee of $5.00 or usual & customary (UCR) pricing
    • MAC pricing is based on the most current MAC list provided by WSI's PBM
  • Reimbursement is the lesser of billed charges or the fee schedule amount.

Brand Medication Fee Schedule

  • Reimbursement is at the WAC plus 8%, plus a single per item dispensing fee of $4.00; or the UCR pricing
  • Reimbursement is the lesser of billed charges or the fee schedule amount

Compounded Prescription Fee Schedule

Compounded prescriptions are reimbursed at the average wholesale price (AWP) minus 72%, plus a single item compounding fee based on the following level of effort (LOE) level or the UCR pricing:

Compound LOEValueReimbursement
Level 1
Mixing liquids using graduated cylinders
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 filling machine
Level 4
USP 797, sterile compounding using hood

Compounded Product Restrictions and Quantity Limitations

WSI restricts the active ingredients of compounded topical pain preparations to the following:

Amitriptyline(Maximum Strength:   7%)
Baclofen(Maximum Strength:   5%)
Bupivacaine(Maximum Strength:   2%)
Clonidine(Maximum Strength: 0.3%)
Cyclobenzaprine(Maximum Strength:   3%)
Dexamethasone(Maximum Strength:   1%)
DMSO(Maximum Strength:   6%)
Gabapentin(Maximum Strength:   6%)
Ketamine(Maximum Strength: 10%)
Ketoprofen(Maximum Strength: 20%)
Lidocaine(Maximum Strength:   5%)
Menthol(Maximum Strength:   5%)
Naltrexone(Maximum Strength: 6mg per capsule)

(Maximum Strength:   3%)

Use limited to the treatment of plantar fasciitis

Additional Restrictions Include:

  • A maximum of 5 active ingredients per compounded preparation
  • A maximum total percent strength of 30% for all combined active ingredients
  • A maximum initial quantity of 60gm for 15 days
  • A maximum subsequent quantity of 120gm for 30 days