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The rule allows prior authorization and reimbursement through the bureau's pharmacy benefits manager for compounded sterile parenteral drug products, drug efficacy study implementation drugs, and extemporaneous and simple compounded prescriptions. The rule also states that the bureau will not reimburse any third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy provider or that purchased pharmacy bills from a pharmacy provider for subsequent submission to the bureau for payment. The bureau is required to retain a registered pharmacist licensed in the state to act as the full-time pharmacy program director to assist the bureau in the review of drug bills.

The bureau also proposed revisions to a rule regarding payments for outpatient medication by self-insured employers. The rule allows medication to be prescribed by any treating provider. Payments to pharmacy providers include both a product cost component and a dispensing fee component, which is $3.50, unless the employer negotiates a payment rate with the pharmacy provider. The pharmacy provider is required to maintain a signature log verifying receipt of applicable covered medications and include prescriber information within bills submitted electronically to the self-insuring employer. The revisions also require a claimant's requests for reimbursement to comply with applicable billing instructions contained in the bureau's provider billing and reimbursement manual. The self-insuring employer may approve reimbursement of a dispensed brand name drug if: 1) an injured worker has a documented, systemic allergic reaction consistent with known symptoms of a medical allergy; and 2) the injured worker tried other A code drugs in the therapeutic class and the intended therapeutic benefit was not achieved or an unacceptable adverse event occurred. Public comments are accepted on the bureau's website until April 15.

April 11, 2011

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