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Workers' compensation pharmacy fee schedule - record layout and instructions

Revised May 5, 2005

You may download the current Medi-Cal pharmacy fee rates here (Zip file, 3.45 MB, updated 07/16/2014, with active pharmaceutical ingredient fee rates (updated July 2013) - also available via ftp to www.dir.ca.gov, anonymous login). The file's record layout and instructions are included in the zip file, as is table 2024.

The record layout is a fixed length ASCII file using the following format:

Two header rows, with field names in the first row and underscores in the second.

Then followed by the records:

NDC number - 11 (11 digits including leading zeros, in pattern 5-4-2)
Filler - 1
Label name - 30
Filler - 1
Lowest Cost- 11(left aligned, usually formatted with decimal point and up to 4 digits after)
Filler - 1
No Sub Cost - 11 (left aligned, usually formatted with decimal point and up to 4 digits after)
Filler - 1
Effective date - 19 (includes time code, formatted YYYY-MM-DD HH:MM:SS )

(Note that the length of the Price Date field in the two header rows is 31 characters)

Then followed by a blank row, and a final row with the record count, e.g. for November 2004:

(830615 row(s) affected)

The file does not include records for expired medications.


Formulae:

For all formulae, the applicable unit price (UP) is the lowest cost, or, only if "No Substitutions" is indicated on the prescription, the no sub cost, and is from the most recent record for which the effective date is equal to or earlier than the date of service.

For all formulae, the discount (D) is based on the date of service, and whether the patient is in a nursing home.
For dates of service on and after 9/1/2004, there is no discount.
For patients in a nursing home, for all dates of service prior to 9/1/04 the discount is 10 cents.
For patients not in a nursing home, for dates of service before July 1, 2004, the discount is 50 cents, for dates of service from 7/1/04 through 8/31/04 inclusive, the discount is 10 cents.

For all formulae, the dispensing fee (DF) depends on the date of service, and whether the patient is in a nursing home.
If the date of service is before 9/1/04, the dispensing fee (DF) is $4.05. If the date of service is on or after 9/1/04, the dispensing fee is $7.25 for patients NOT in a nursing home, and $8.00 for patients in a nursing home

For simple prescription pricing, the Medi-Cal price (MP) is the unit price (UP) times
the number of metric decimal units (MDU) (without rounding) plus the dispensing fee (DF):
MP = (UP x MDU) + DF

The usual and customary price (CP) is the actual usual and customary price, including any dispensing fee.

The payment price (PP) is the lower of the Medi-Cal price or the usual and customary price (CP), minus the discount:
PP = (lesser of(MP,CP)) - D

For compound prescription pricing, the compound dispensing fee (CDF) is dependent on route of administration, dosage form, and date of service.

For all dates of service, the compound dispensing fee (CDF) is the sum of the dispensing fee (DF) plus the compounding fee (CF) plus the sterility fee (SF):
CDF = DF + CF + SF

For all dates of service, the number of containers (NC) is multiplied by the compound dispensing fee only for routes of administration 4 - injection and 14 - perfusion. Otherwise the number of containers (NC) is considered to be one (1).

For all dates of service, the sterility fee (SF) is the lesser of the usual and customary sterility fee and the maximum sterility fee allowed for that route of administration (see table 2024).

For all dates of service, the compounding fee (CF) is the fee allowed for that route of administration and dosage metric decimal units, or, if that amount is zero, then the compounding fee allowed for the applicable dosage form and range of dosage metric decimal units (see table 2024).

For compound prescription pricing, the Medi-Cal price (MP) is the sum, for each ingredient (i) in the compound prescription, of the unit price (UP) times the number of metric decimal units (MDU) of that ingredient (without rounding), plus the compound dispensing fee (CDF) times the number of containers (NC). The total number of ingredients is the ingredient count (IC):
MP = [Sfor i=1 to IC ( UPi x MDUi )] + (NC x CDF)

The usual and customary price (CP) is the actual usual and customary price, including all dispensing or compounding fees.

The payment price (PP) is the lower of the Medi-Cal price or the usual and customary price, minus the discount:
PP = (lesser of(MP,CP)) - D


Physician dispensed pharmaceuticals

Legislation that became effective on January 1, 2012 places new caps on fees for pharmaceuticals dispensed by physicians. These new caps are contained in Labor Code section 5307.1.