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Rule: 24.29.1529 Prev     Up     Next    
Rule Title: PRESCRIPTION DRUGS FEE SCHEDULE
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Department: LABOR AND INDUSTRY
Chapter: WORKERS' COMPENSATION AND OCCUPATIONAL DISEASE
Subchapter: Nonfacility Service Rules and Utilization Rules
 
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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24.29.1529    PRESCRIPTION DRUGS FEE SCHEDULE

(1) In addition to the limitations on the payments for and dispensing of prescription drugs as set out by 39-71-727, MCA, the following apply:

(a) The reimbursement rate for prescription drugs is based upon the rate in effect on the date the drug is dispensed.

(b) Reimbursement rates to retail pharmacies for brand-name drugs are limited to the lesser of:

(i) the price charged for the prescription drug at the time of dispensing; or

(ii) the average wholesale price (AWP), minus 10 percent, at the time of dispensing, plus a dispensing fee, not to exceed $3.00 per prescription drug.

(c) Reimbursement rates to retail pharmacies for generic-name drugs are limited to the lesser of:

(i) the price charged for the prescription drug at the time of dispensing; or

(ii) the AWP, minus 25 percent, at the time of dispensing, plus a dispensing fee, not to exceed $3.00 per prescription drug.

(d) For the purposes of this rule, average wholesale prices must be updated monthly.

(2) If, prior to liability for a claim being accepted by the insurer, an injured worker has personally paid for prescription drugs, prescribed for a condition for which liability is subsequently accepted, the injured worker is entitled to a refund of the price paid by the injured worker for the prescription drug.

(a) The insurer, when accepting liability for a condition for which a prescription drug has been prescribed, must, upon receiving a proper receipt, reimburse the injured worker the retail price paid.

(b) After the injured worker has been reimbursed by the insurer, the pharmacy must, upon request by the insurer, reimburse the insurer for the difference in the amount paid by the injured worker and the amount provided by the fee schedule.

History: 39-71-203, MCA; IMP, 39-71-727, 39-71-743, MCA; NEW, 2007 MAR p. 1192, Eff. 8/24/07; AMD, 2007 MAR. p. 1676, Eff. 10/26/07; AMD, 2007 MAR p. 2011, Eff. 12/7/07.


 

 
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