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The insurer must pay the pharmacy's wholesale price for compound cream



An insurer is required to pay a pharmacy for a compound cream that is awarded to a worker's compensation claim based on a nationally recognized fee schedule, the Pennsylvania Commonwealth Court held Tuesday.

I Indemnity Insurance Co. in North America v. Bureau of Workers Compensation Fee Review Hearing Office the court found that the insurer did not show that the cream price was calculated using a "fictitious" number.

In 2013, a worker suffered a back injury and was prescribed a compound medical cream consisting of gabapentin, flurbiprofen, ketamine, cyclobenzaprine, Lidoderm and bupivacaine to treat her injury. The pharmacy invoiced Indemnity Insurance Co. in North America $ 7,255 for the cream, and the insurer's third party administration reduced the bill by 95%, arguing that the fees exceeded the guidelines of the Pennsylvania Compensation Act. Damages paid $ 305 on the pharmacy's invoice.

The pharmacy filed a fee review application and the Bureau of Workers' Compensation Fee Review Hearing Office ordered the insurer to pay an additional $ 6,336 plus interest, based on compensation for any unlisted or unclassified. drugs under the law for government workers will be based on 1

10% of the average wholesale price. fictitious number – but the interrogation office confirmed the decision.

Compensation appealed, but the Commonwealth Court upheld the interrogation office's decision. The Court found that the Compensation's experts did not provide any evidence to support their proposed "correct" unit prices for the various creams in the cream, nor any evidence that the average wholesale price was "fictitious."

The Court also dismissed the Compensation's claim that the Agency's regulation "incorrectly links medical compensation to a (average wholesale price) set by private companies", noting that the law allows the Agency to use information from all nationally recognized price plans compiled from the market.

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