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Good Evening
10:36:43 PM CDT
Wednesday, September 17, 2014

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Pharmacy 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).

Fee Schedule for generic medication:
  • 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 PMSI
  • Reimbursement is in full for any charges submitted that are less than or equal to the maximum allowable fee
Fee Schedule for Brand medication:
  • Reimbursement is at the WAC plus 8%, plus a single per item dispensing fee of $4.00; or the UCR pricing

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 LOE Value Reimbursement
Level 1
Mixing liquids using graduated cylinders
11 $10.00
Level 2
Triturate powder and mix by geometric dilution, mix creams, ointments, emulsions and liquids by hand or by using unguator
12 $15.00
Level 3
Suppository mold, lollipop mold and toche/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
13 $20.00
Level 4
USP 797, sterile compounding using hood
14 $25.00




Compounded Topical Pain Preparations
Product Restrictions and Quantity Limitations

ND Workforce Safety & Insurance restricts the active ingredients of compounded topical pain preparations to the following:

Amitriptyline(Maximum Strength: 4%)
Baclofen(Maximum Strength: 5%)
Bupivacaine(Maximum Strength: 2%)
Clonidine(Maximum Strength: 0.3%)
Cyclobenzaprine    (Maximum Strength: 3%)
Gabapentin(Maximum Strength: 6%)
Ketamine(Maximum Strength: 10%)
Ketoprofen(Maximum Strength: 20%)
Lidocaine(Maximum Strength: 5%)
Piroxicam(Maximum Strength: 3%)   Use limited to the treatment of plantar fasciitis

Additional Restrictions Include:
  • A maximum of five (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

For Durable Medical Equipment (DME) or supply items (i.e. gauze, tape etc.); submit charges to WSI in paper format or electronically in the CMS 1500 format. WSI does not directly reimburse injured workers for medications, DME or supply items.

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