Illinois – Final Physician-Dispensed Pharmacy Rule Published

Released: 02/06/2013   By: Abby Wright

The IWCC’s final repackaged drug repricing methodology was published in the December 7 edition of the Illinois Register.

As we covered in our 11/20/2012 post, the effective date of the change is November 20, 2012. The Medical Fee Advisory Board did clarify at its December meeting that the pricing methodology is for dates of service of 11/20/2012 and later. The final adopted amendment did not contain changes to the language from the previously published proposed rulemaking.

The implemented rules begin on page 17108 (PDF page 315) of Volume 36, Issue 39 of the Illinois Register.

From the IL Workers’ Compensation Commission’s Notice of Adopted Amendment:

Summary and Purpose of Rulemaking: The amendment implements Section 8.2(a-3) of the Workers’ Compensation Act by specifying that when a prescription dispensed outside of a licensed pharmacy is repackaged, the Average Wholesale Price used to determine the maximum reimbursement shall be the Average Wholesale Price for the underlying drug product, as identified by its National Drug Code (NDC) from the original labeler.
Pursuant Section 8.2(a-3) of the Act, only prescriptions dispensed outside of a licensed pharmacy are subject to a fee schedule. The fee schedule sets the maximum reimbursement levels for these prescriptions. For prescriptions dispensed outside of a licensed pharmacy, Section 8.2(a-3) provides that the fee schedule shall not exceed the Average Wholesale Price, plus a dispensing fee of $4.18. Average Wholesale Price is determined by the NDC set forth in Medispan.
The amendment addresses a practice known as “repackaging” which means that the prescription will be purchased and then repackaged in different quantities. It is then given a new NDC number with a higher Average Wholesale Price. Thus, the “repackaging” avoids the NDC for the drug from the original labeler. “Repackaged” drugs are typically dispensed by physicians in their offices.

(Taken from IL Workers’ Comp Reform Guide)

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