Effective November 20, 2012, Illinois adopted new rules governing the reimbursement and billing of physician-dispensed drugs. The new rules set the maximum reimbursement amount for drugs dispensed outside of a licensed pharmacy to the average wholesale price (AWP) or its equivalent of the drug product, plus a $4.18 dispensing fee. The new rules also state that if a prescription has been repackaged, the AWP used to determine the maximum reimbursement shall be the AWP for the underlying drug product, as identified by its National Drug Code (NDC) from the original manufacturer.
This report is part of a series of WCRI studies that examine the effects of regulatory or legislative changes to the rules governing reimbursement for physician-dispensed prescriptions. In this study, we examine the impact of the price-focused reform on the frequency and costs of physician dispensing in Illinois, using detailed transaction data for physician- and pharmacy-dispensed prescriptions filled by injured workers up through the first quarter of 2014 that capture the initial 15 months of post-reform experience. With additional data over a longer time period, we will examine the subsequent effects of the reforms.
Monitoring Illinois Reforms on Physician Dispensing. Dongchun Wang, Vennela Thumula, and Te-Chun Liu. July 2016. WC-16-47.
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