WSI covers the cost of medications and supplies used to treat a condition accepted on an injured employee's claim. Coverage includes prescriptions, over-the-counter medications, durable medical equipment (DME) and medical supply items. WSI does not provide direct reimbursement for these charges, which a provider or pharmacy must submit through the Pharmacy Benefit Manager. Below is additional information regarding WSI's pharmacy program.
WSI's pharmacy plan design incorporates industry standards to ensure point of sale processing of pharmacy charges. The main elements include:
- Supply Limits - Allows 34 days for acute and 60 days for chronic medication
- Formulary/Medication Restrictions - Lists medication exclusions, quantity limitations, and prior authorization requirements
- Prior Authorization for Brand Necessary Medications
- WSI may authorize brand medication with documentation of trial and failure or adverse reaction to the generic equivalent
- An injured employee may request a brand medication but is responsible to pay the cost difference between the generic and brand medication
WSI reimburses for medications dispensed directly from a provider's medical clinic when billed electronically to our current Pharmacy Benefit Management (PBM) using the current NCPDP pharmacy transaction standard. See North Dakota Administrative Code § 92-01-02-45.1(3). WSI does not directly reimburse a provider or an injured employee for medications.
WSI contracts with Envolve Pharmacy Solutions, a national pharmacy benefit management company, to process pharmacy charges. This partnership allows access to over 65,000 pharmacies nationwide while providing an efficient process for the pharmacies. Use the Pharmacy Locator to find a participating pharmacy. In the search criteria, use Group Number 8001.
A pharmacy filling a medication must submit charges electronically to Envolve Pharmacy Solutions. To contract with Envolve Pharmacy Solutions, contact them by fax at 866-912-6293 or email firstname.lastname@example.org. For questions on pharmacy contracts, call Envolve at 800-460-8988 and ask for the Pharmacy Networks Department.
To ensure proper processing, use the following:
BIN Number: 008019
Rx Group Number: 8001
ID Number: SSN or WSI Claim Number
The First Fill Program allows a pharmacy to dispense medication immediately to an injured employee while ensuring payment to the pharmacy. Under this program:
- The date of first fill must be within 30 days of the injury date.
- A pharmacy must contact Envolve Pharmacy Solutions with the following patient information:
- Name (first and last)
- Date of birth
- Social Security Number
- Date of injury
- Employer's name
- WSI allows an injured employee 1 first fill every 6 months, regardless the number of claims filed.
- The program does not cover all medications, e.g., any medication requiring prior authorization (Status PA). For a list of excluded products, see the Pharmacy Benefit Management (PBM) Program First Fill Product Exclusions.
- A pharmacy receives payment for the initial 7-day prescription not to exceed a total of $100.
For further assistance on the First Fill Program, contact Envolve Pharmacy Solutions Help Desk at 844-895-0395.
The Formulary/Medication Restrictions list outlines the therapeutic classes for North Dakota WSI's benefit plan. Medications listed on the formulary do not guarantee coverage and are subject to specific WSI policy and determination of appropriateness for the accepted conditions.
Guidelines for WSI's Formulary/Medication Restrictions:
- WSI's Pharmacy and Therapeutics Committee has reviewed the Formulary/Medication Restrictions
- The list includes the limits and restrictions for each product
- Products requiring prior authorization are subject to specific WSI policy and determination of appropriateness for accepted condition(s)
A medication on the formulary list will have one of the following designated statuses:
- (PA) Prior Authorization - Prior authorization required before filling prescription
- (MDD) Max Daily Dose - Limit on the number of times the drug can be taken per day
- (QL) Quantity Limit - Limit on the amount of drug coverage per prescription or within a specific time frame
- (C) Custom - Unique restrictions apply to this drug (non-formulary drug). Use the Formulary/Medication Restrictions to find an alternative medication
A medication not on the formulary list is considered Non-Formulary, and WSI does not normally cover it.
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
WSI reimburses for compounded medication based on the level of effort (LOE). For more information click here.
Prior to submitting a request for authorization, a provider prescribing medication is responsible for reviewing the Formulary/Medication Restrictions list to determine whether the medication requires authorization. For a drug requiring prior authorization, complete the Provider's Request for Medication Prior Authorization (M11) form and fax it with supporting documentation to 888-786-8695.
WSI requires prior authorization for Brand Necessary medication, also referred to as Dispense as Written (DAW). A provider requesting Brand Necessary medication should review the Prior Authorization for Brand Necessary Medications treatment policy for information on WSI's parameters for coverage.
To request authorization, complete the Provider's Request for Medication Prior Authorization (M11) form and fax it with supporting medical notes to 888-786-8695. Medical notes detailing the objective medical evidence of the adverse reaction and/or inadequate response to the generic equivalent medication must accompany the request.
Approval for a brand name medication is specific to the medication, strength, and dosage and is valid for a maximum of one year. To renew authorization for a brand name medication, a provider must submit the M11 form on an annual basis.
The Pharmacy Fee Schedule is based on Wolters Kluwer Medispan Electronic Drug file wholesale acquisition cost (WAC) or the organization's pharmacy benefit management company's maximum allowable cost (MAC), when applicable.
Click here for additional information.
For durable medical equipment (DME) or medical supply items filled in a pharmacy setting, submit charges electronically to Envolve Pharmacy Solutions. These items require prior authorization prior to processing.
Covered items: Gauze, tape, bandages, bladder protection pads, catheter items, Xeroform dressing, Tegaderm dressing, Duoderm, Kerlix, syringes, etc.
Non-covered items: Therma Care, hot and/or cold packs
Envolve Pharmacy Solutions is not able to add products to its system without an NDC. Continue to submit paper bills for DME and medical supplies without an NDC to WSI for payment to the pharmacy.
WSI does not directly reimburse an injured employee for medications, DME, or medical supply items.