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Policy Matters Alert

Important legislative and regulatory updates

California pharmacy fee schedule updates coming soon

June 13, 2025 · Public Policy & Regulatory Affairs Team

In just a little over two weeks (July 1), the California Division of Workers’ Compensation Division (DWC) will roll out the new pharmacy fee schedule tied to the state Medicaid (Medi-Cal) pharmacy rates. The new fee schedule will be based upon several feeds from Medi-Cal which will be made available by the DWC on their website.

The basis for pharmacy reimbursement rests upon two specific indications and feeds from the DWC:

Reimbursement for the drug ingredient/component derived from information found in the pharmaceutical fee data file consisting of the “lowest cost” drug ingredient rate for most medications
The “no substitution cost” drug ingredient rate file when a medication is dispensed under the indication of “dispense as written” or “do not substitute” by the prescribing physician

These file feeds will help the DWC determine the proper reimbursement for medications dispensed to an injured worker.

For the professional dispensing fee component, reimbursement will be based upon the Medi-Cal National Provider Identifier file. Pharmacies with a larger volume of business –will receive a $10.05 dispensing fee while smaller volume pharmacies will receive the higher $13.20 dispensing fee for all medications dispensed to an injured worker. Physicians who dispense from their office are still subject to all formulary and workers’ compensation requirements and are to receive the $10.05 dispensing fee.

The adopted regulations also address specific reimbursement of the drug component and dispensing fees for compounded and over-the-counter medications.

As implementation of the new fee schedule reimbursement processes quickly approaches, we urge all impacted stakeholders and our clients to reach out to any billing, bill review and pharmacy processing entities to ensure they will likewise comply with the new requirements.

The adopted fee schedule regulations can be found at this link.

The Pharmaceutical Fee Data and NPI Identifier file(s) can be found here.

Should you have any questions, please reach out to your Account Management team member or the PPRA team at optumwc.policymatters@optum.com

Additional Optum resources:

For more information on these policy developments and others we have been tracking this year, be sure to visit our Legislative and Regulatory Tracker. Bills or regulations can be filtered by insurance line, topic, status and jurisdiction.

If you have questions on these or any other public policy developments, please contact our team at OptumWC.PolicyMatters@optum.com.

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