1. DWC

Workers' compensation pharmacy fee schedule

Simple Pharmacy 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, 9789.40.2, 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 reimbursement 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

  • NDC Number – This is the 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
  • Date of Service – This is the date a drug was dispensed. After PID
  • Total Metric Decimal Units Dispensed – This is the amount of drug dispensed using the National Council for Prescription Drug Programs (NCPDP) standard.  A description of the how units are determined is provided here
  • Usual and Customary Fee – This is the amount the provider charges the general public for the same drug and quantity and is inclusive of any professional dispensing fee charged by the provider.

Optional Fields

  • NPI Number – National Provider Identifier is a 10-digit number that uniquely identifies a healthcare provider (e.g. pharmacy, physician, clinic, hospital).  This is used to identify providers who are eligible for an enhanced dispensing fee under the Medi-Cal program.
  • Do Not Substitute – Check this box when a prescriber has indicated that on a prescription “Do Not Substitute” or “Dispense as Written”. This typically occurs when a prescriber wants the pharmacy to dispense a specific brand of drug.

NDC Number Not Found

When an NDC number is not found, additional fields will appear to determine if the drug is a repackaged product.  If the drug is not a repackaged product, calculation of a MAXIMUM REASONABLE FEE cannot occur.  If the drug is a repackaged product, the “NDC number repackaged” box must be checked and the “Underlying Product NDC Number” must be entered.  If the underlying NDC number is not found, a calculation of the MAXIMUM REASONABLE FEE will not occur.

Outputs

  • "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
  • NDC Number – NDC number entered by user
  • Label Name – Label name of the drug from the PFS file based on the NDC number entered
  • 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
  • Number of Units – Metric decimal units entered by the user
  • Unit Price – price per metric decimal unit from the PFS file based on the user entered Date of Service
  • Total Ingredient Cost – calculated amount equal to the product of Number of Units times Unit Price
  • Dispensing Fee – allowed maximum dispensing fee based on user entered NPI number
  • Medi-Cal Price - calculated amount equal to the Total Ingredient Cost plus the Dispensing Fee
  • Usual and Customary Price - the user entered Usual and Customary Price
  • Maximum Reasonable Fee - amount equal to the lower of the Medi-Cal Price and the Usual and Customary Price

April 2025