Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director -Administrative Rules
Article 5.3. Official Medical Fee Schedule

§9789.40.1. Pharmaceutical Fee Data File for Pharmacy and Physician Dispensed Pharmaceuticals; National Provider Identifier File for Pharmacy Dispensed Pharmaceuticals; for Products Dispensed and Services Rendered on or after July 1, 2025.

This section is effective where applicable pursuant to sections 9789.40.2 through 9789.40.7.

(a) The Pharmaceutical Fee Data File setting forth the Division's calculation of “lowest cost” and “no substitution cost” drug ingredient rates based on the Medi-Cal methodology will be made available on the Division of Workers' Compensation's Official Medical Fee Schedule web page.

(1) The drug ingredient “lowest cost” means the rate set forth in the Pharmaceutical Fee Schedule Data File, as calculated by the division based upon the lowest of:

The National Average Drug Acquisition Cost (NADAC) of the drug, or when no NADAC is available, the Wholesale Acquisition Cost (WAC) + 0%; or

The Federal Upper Limit (FUL); or

The Maximum Allowable Ingredient Cost (MAIC).

(2) The drug ingredient “no substitution cost” means the rate set forth in the Pharmaceutical Fee Schedule Data File, as calculated by the division. For products where the “no substitution cost” differs from the “lowest cost”, the division has calculated the cost based upon the NADAC of the drug, or when no NADAC is available, the Wholesale Acquisition Cost (WAC) +0%.

(3) The Division of Workers' Compensation will post an updated Pharmaceutical Fee Data File on a weekly basis absent extenuating circumstances.

(A) Payers shall begin calculating the maximum reasonable fee pursuant to sections 9789.40.2 through 9789.40.7 based on each new file not later than the second calendar day after posting of the Pharmaceutical Fee Data File on the division's website.

(B) The costs for each NDC are effective for products dispensed on or after the effective date listed in the Pharmaceutical Fee Data File.

(C) For retroactive cost changes within the Pharmaceutical Fee Data File or costs used during the implementation period allowed pursuant to paragraph (a)(3)(A), payers shall re-adjudicate previously paid claims to correct the cost used for the date a drug was dispensed upon submission of provider's request for second review pursuant to section 9792.5.5.

(4) The status of each NDC as Legend (prescription required) is indicated in the Pharmaceutical Fee Data File with “Y” in the Legend Indicator field for the cost effective date of the NDC. The status of each NDC as Non-Legend (non-prescription or over-the-counter) is indicated in the PFS file with “N” in the Legend Indicator field for the cost effective date of the NDC.

(b) The Medi-Cal National Provider Identifier (NPI) file listing pharmacy NPIs eligible for the higher tier dispensing fee, and listing the effective dates of eligibility, will be made available on the Division of Workers' Compensation's Official Medical Fee Schedule web page.

(1) The Division of Workers' Compensation will post an updated Medi-Cal NPI file on a weekly basis absent extenuating circumstances.

(2) A pharmacy is eligible for the higher dispensing fee for products dispensed during the effective dates listed, where the effective date period is listed as Active (“A”).

(3) Payers shall begin calculating the maximum reasonable pharmacy dispensing fee pursuant to sections 9789.40.2, 9789.40.3, 9789.40.4 and 9789.40.5 based on each new Medi-Cal NPI file not later than the second calendar day after posting the Medi-Cal NPI file on the division's website.

(4) For retroactive NPI effective date changes within the Medi-Cal NPI file, retroactive changes of Active/Inactive status, or for NPI effective dates used during the implementation period allowed pursuant to paragraph (b)(3), payers shall re-adjudicate previously paid claims to correct the dispensing fee upon submission of provider's request for second review pursuant to section 9792.5.5.

Credits

Note: Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 4603.2 and 5307.1, Labor Code.

History

1. New section filed 12-11-2024; operative 7-1-2025. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2024, No. 50).