1. DWC

Workers' compensation pharmacy fee schedule

Compound Physician Prescription Calculator

This calculator is provided as a service to the workers’ compensation community. The intent of this calculator is to provide an estimate of the MAXIMUM REASONABLE FEE based on the information provided by the user and pricing information contained within the Pharmacy Fee Schedule (PFS). PFS data is located at https://www.dir.ca.gov/ftproot/PFSandNPI.zip. The calculations performed comply with regulatory requirements at sections 9789.40, 9789.40.1, 9789.40.4, 9789.40.6, 9789.40.7.

The calculated MAXIMUM REASONABLE FEE is not a guarantee by the Division of Workers Compensation of provider reimbursement. Other factors that might affect reimbursement such as contractual reibursement rates between a provider and payer are not included in calculations.

INSTRUCTIONS

The following information is required to perform a calculation. The values and their descriptions are as follows:

Required Fields

  • Date of Service – Date a drug was dispensed
  • Dosage Form – Select from list. Choose the closest description to your compound’s final form. See https://www.dir.ca.gov/dwc/pharmfeesched/table2024.pdf for list.
  • Total Metric Decimal Units Dispensed – Total amount by weight (gm) or volume (ml) of the final compound per container
  • Route of Administration – Select from list.  If not listed choose the closest description to route of administration.  See https://www.dir.ca.gov/dwc/pharmfeesched/table2024.pdf for list.
  • Number of Containers – Total number of containers being dispensed. For most compounds this is limited to 1 container.
  • Sterility fee per Container – Per container amount charged for testing the sterility of the compound. See https://www.dir.ca.gov/dwc/pharmfeesched/table2024.pdf for list of dosage forms and maximum amount allowed for the sterility fee per container. If left blank or set to zero, the allowed sterility fee will equal zero.
  • Compounding fee per container – Per container amount charged to make the compound. See https://www.dir.ca.gov/dwc/pharmfeesched/table2024.pdf for maximum amount allowed for compounding fees per container. If left blank or set to zero, the allowed compounding fee will equal zero.
  • Usual and Customary Price – Amount the provider charges the general public for the same drug and quantity and is inclusive of any compounding, sterility testing or professional dispensing fees charged by the provider.
  • For Each Ingredient in the compound:
    • NDC Number –National Drug Code number of the drug in the 11-digit format.  The following link provides information about NDC formats and how to convert federal Food and Drug Administration (FDA) standard NDC numbers to an 11-digit NDC number
    • Ingredient Metric Decimal Number of Units – Total number of units of the NDC used in the compounded drug product.
    • Documented Paid Cost – Documented Paid Cost means the price paid by the physician for the drug product(s), net of discounts and rebates, evidenced by documentation of the price actually paid by the physician for the drug products.  After a documented paid cost is entered, a "Total DPC for Ingredient" is calculated. This amount is the product of the entered DPC times the number of units.  Total DPC for Ingredient is needed to calculate the Maximum Reasonable Fee.  See full regulatory definition at Title 8, section 9789.40.7(b)
    • Usual and Customary Price (per unit) – Amount the provider charges the general public for the same drug ingredient and quantity.
    • Do Not Substitute – (Optional Field) Check this box when a prescriber has indicated that on a prescription “Do Not Substitute” or “Dispense as Written” for the drug ingredient. This typically occurs when a prescriber wants to dispense a specific brand of drug.

NDC Number Not Found

When an NDC number is not found for an ingredient, the total ingredient cost for the individual ingredient is set to zero dollars ($0.00).

Two or More Ingredients

There must be two or more valid ingredients, i.e. the NDCs must be found in the PFS file, for the calculator to work.  If only one or fewer ingredients is found, the calculator will error out and notify the user of the need for at least two valid ingredient NDCs.

Output Fields

  • "This information supplied on DATE" – This is a system generated date based on the date the calculator was used.
  • Date of Service - Date of service as entered by the user
  • Ingredient NDC Number – NDC number entered by user
  • Ingredient Label Name – Label name of the drug from the PFS file based on the NDC number entered
  • Ingredient Price Date (Start) -Price date from the PFS which identifies the first date the Unit Price shown became active relative to the Date of Service entered by the user
  • Ingredient Number of Units – Metric decimal units entered by the user
  • Ingredient Unit Price – price per metric decimal unit from the PFS file based on the user entered Date of Service
  • Ingredient Usual and Customary (U&C) per Unit – Usual and Customary Price as entered by the user
  • Total Ingredient Cost – calculated amount equal to the product of Ingredient Number of Units times Ingredient Unit Price
  • Total Cost for all Ingredients – calculated amount equal to the sum of all the Total Ingredient Cost values calculated for each ingredient listed
  • Dispensing Fee – allowed maximum dispensing fee per container based on user entered NPI number
  • Sterility Fee (Table value) – maximum sterility fee per container allowed based on dosage form or route of administration entered by the user
  • Sterility Fee (User entered) – sterility fee per container amount entered by the user
  • Sterility Fee – the sterility fee per container reimbursement allowed which equals the lower of the maximum sterility fee (table value) or the user entered sterility fee
  • Compounding Fee (Table value) - maximum compounding fee per container allowed based on dosage form, route of administration, and total metric decimal units entered by the user
  • Compounding Fee (User entered) – compounding fee per container amount entered by the user
  • Compounding Fee - the compounding fee per container reimbursement allowed which equals the lower of the maximum compounding fee (table value) or the user entered compounding fee
  • Number of Containers – number of containers entered by the user
  • Physician Fee Total – calculated amount the equals the sum of the allowed per container Dispensing Fee, Sterility Fee and Compounding Fee times the number of containers
  • Calculated Physician Price - calculated amount equal to the Total Cost of All Ingredients plus the Physician Fee Total
  • Total Ingredient Documented Paid Cost – calculated value equal to the sum of the Total DPC For Ingredient for all ingredients
  • Total Ingredient Documented Paid Cost times 300% - calculated amount equal to the product of the Total Ingredient Documented Paid Cost times three (3)
  • Total Ingredient Documented Paid Cost plus $20 - calculated amount equal to the sum of the Total Ingredient Documented Paid Cost plus $20
  • Maximum Calculated Physician Price Payable – equals the lowest of the Calculated Physician Price, Total Ingredient Documented Paid Cost times 300%, and the Total Ingredient Documented Paid Cost plus $20
  • Usual and Customary Price - the user entered Usual and Customary Price for the completed compounded drug
  • Maximum Reasonable Fee -  amount equal to the lower of the Maximum Calculated Physician Price Payable and the Usual and Customary Price

April 2025