Michigan Administrative Code
Department - Labor and Economic Opportunity
Workers Compensation Agency
Workers' Compensation Health Care Services Rules
Part 10 - REIMBURSEMENT
Subpart A - Eligibility for premium tax credit
Section R. 418.101003a - Reimbursement for dispensed medications

Universal Citation: MI Admin Code R. 418.101003a

Current through Vol. 24-16, September 15, 2024

Rule 1003a.

(1) Prescription medication must be reimbursed at the average wholesale price (AWP) minus 10%, as determined by Red Book or Medi-Span, adopted by reference in R 418.10107, plus a dispense fee. All of the following apply to reimbursements: The dispense fee for a brand name drug is $3.50. The dispense fee for a generic drug is $5.50.

(c) Reimbursement for repackaged pharmaceuticals is at a maximum reimbursement of AWP minus 10% based on the original manufacturer's NDC number, as determined by Red Book or Medi-Span, adopted by reference in R 418.10107, plus a dispensing fee of $3.50 for brand name and $5.50 for generic.

(d) All pharmaceutical bills submitted for repackaged products must include the original manufacturer or distributer stock package national drug code or NDC number.

(e) When an original manufacturer's NDC number is not available in either Red Book or Medi-Span, as adopted by reference in R 418.10107, and a pharmaceutical is billed using an unlisted or not otherwise specified code, the payer shall select the most closely related NDC number to use for reimbursement of the pharmaceutical.

(2) Over-the-counter drugs (OTC's), dispensed by a provider other than a pharmacy, must be dispensed in 10-day quantities and be reimbursed at the average wholesale price, as determined by Red Book or Medi-Span, adopted by reference in R 418.10107, or $2.50, whichever is greater.

(3) All commercially manufactured topical medications that do not meet the definition of custom compound dispensed by a pharmacy or a provider, must not exceed a 30-day supply. Regardless of dispensing party, reimbursement is a maximum of the acquisition cost, plus a single dispense fee. The single dispense fee is $8.50. A provider shall only be reimbursed 1 dispense fee per topical medication in a 10-day period.

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