Ala. Admin. Code r. 480-5-5-.21

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.21 - Prescribed Medications

(1)Prescribed Medication Services

(a) "Medicinal drugs" or "drugs" shall be defined as "legend" or "prescription" drugs that may only be dispensed when prescribed by a currently licensed provider authorized by law to prescribe drugs.

(b) "Medicines" shall be defined as drugs prescribed by an authorized health care provider and include generic drugs or single-source patented (brand name) drugs for which there is no generic equivalent.

(c) Whenever medically appropriate, a pharmaceutical and therapeutically equivalent drug product may be selected by a physician or other authorized practitioner in accordance with the requirements of Code of Ala. 1975, § 34-23-8.

(d) Reimbursement

1. Reimbursement to the provider shall not exceed the amount calculated by the pharmaceutical reimbursement formula for prescribed drugs as specified in the Maximum Fee Schedule for Pharmaceutics.

2. The provider shall bill for prescription drugs or "medicines" on the appropriate form as stated in Rule 480-5-5-.22.

(e)Reimbursement Formula/Methodology

1. The pharmaceutical reimbursement formula for prescribed drugs is contained in the Maximum Fee Schedule for pharmaceutics.

(1) Average Wholesale Price (AWP) shall be determined from the most recent issue, including updates, of Drug Topics Red Book, Prescription Pricing Guide, American Druggist Blue Book, or similar pharmaceutical publications.

(ii) The reimbursement amount shall be determined by multiplying the AWP by the percent factor as published in the Maximum Fee Schedule for Pharmaceutics and adding the dispensing fee.

(2) "Patent" or "Proprietary Preparations"

(a) Billing

1. Pharmacists shall bill and be reimbursed their usually and customary charge for any "over-the-counter drug."

2. The reimbursement formula shall not apply to "over-the-counter drugs" and no dispensing fee shall be reimbursed.

3. The following data shall appear on the billing form:

(i) Employee's Name;

(ii) Employee's Address;

(iii) Employee's Identifying Number;

(iv) Date Prescription was Filled;

(v) Prescription Number;

(vi) National Drug Code;

(vii) Drug Name;

(viii) Drug Quantity;

(ix) Total Charge;

(x) Employee's or Pharmacist's Signature; and

(xi) Provider's Name and Address.

Ala. Admin. Code r. 480-5-5-.21

New Rule: Filed August 9, 1996; effective September 13, 1996. Amended: Filed December 5, 2008; effective January 9, 2009.

Author: Workers' Compensation Division

Statutory Authority:Code of Ala. 1975, § 25-5-293