The South Carolina Workers’ Compensation Commission approved changes to the Medical Services Provider Manual, effective April 1, 2022. The changes adopted include differences in the proposed rules for pharmacy released by the Commission in December 2021. One of the biggest changes from the proposed rule to the adopted language involved prescription topical medications. The new reimbursement rule for non-compound prescription topical medications is $240 for a 30-day supply, pro-rated based on the number of day supply dispensed, not to exceed 90 days, plus a single dispensing fee of $5. Additionally, physicians are urged to prescribe therapeutically equivalent medications or over the counter (OTC), when available, in lieu of a prescription-strength topical medication.
The reimbursement proposed for topical compound medications was consistent with the adopted language by the Commission. Reimbursement is a $5 dispensing fee plus the lesser of Average Wholesale Price (AWP) for each ingredient’s original National Drug Code (NDC), or $240 for a 30-day supply, pro-rated based on the number of days dispensed, not to exceed 90 days. Prior authorization is required for compound drugs for each dispensing. Automatic refilling is not allowed, and refills may require documentation of effectiveness and functional improvement. And similar to the rules for prescription topical medications, the Commission urges physicians to prescribe therapeutically equivalent medications or OTC when available in lieu of a prescription-strength topical medication.
Other pharmacy-related changes that are effective April 1, 2022 include reimbursement limitations for non-prescription strength patches. Non-prescription strength patches shall be reimbursed as the lesser of actual cost + 20% or $70 for a 30-day supply, pro-rated based on the number of days dispensed.
For a complete summary of the changes and links to the full fee schedule, please visit.
If you have any additional questions about this information, please contact your client services manager.