CA: WCAB Provides Guidance on Reimbursement of Lien for Repackaged Pharmaceuticals

CA: WCAB Provides Guidance on Reimbursement of Lien for Repackaged Pharmaceuticals

Ramon Mendoza v. J. Buckbinder Industry, Inc., Insurance Company of the West

Liens--Repackaged Pharmaceuticals--WCAB rescinded WCJ's finding that lien claimant California Pharmacy Management was entitled to partial reimbursement of its lien for repackaged drugs dispensed by treating physician between 1/1/2004 and 2/28/2007 to  applicant/laborer with injuries to thoracic spine, lumbar spine, cervical spine, and both legs on 1/11/2006 and from 1/2005 through 1/2006, when WCAB found that lien claimant's claim for reimbursement was governed by 2003 Official Medical Fee Schedule (OMFS) as Medi-Cal system did not include repackaged pharmaceuticals, that to obtain reimbursement under 2003 OMFS, physician provider must prove his usual charge--i.e., amount paid for pharmaceuticals--and if charge is disputed, defendant must prove that formula set forth in OMFS provides for a lesser reimbursement than physician's usual charge, and that, here, there was no evidence presented as to what treating physician paid for pharmaceuticals dispensed to applicant; WCAB remanded matter for development of record regarding treating physician's actual charges and stated that if pharmaceuticals dispensed by treating physician were samples provided to him at no charge, there can be no reimbursement, that charges for medication dispensed cannot be higher than brand name equivalent drug, and that if there is no evidence of the AWP for a pharmaceutical, treating physician is entitled to reimbursement for his actual charge if medication was reasonably required. © Copyright 2010 LexisNexis. All rights reserved.

Read the panel decision

Source: Calif. Workers’ Compensation Appeals Board