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At a Glance:
Title:
11172
Date:
June 28, 2011
Status:
Medical Fees

11172

June 28, 2011

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUES

A contested case hearing was held on May 24, 2011 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider) Pharmacy, Petitioner, is not entitled to additional reimbursement for the compensable injury of (Date of Injury) in the amount of $66.39 for 30 units of Sonata 10 MG Capsule dispensed to Claimant on July 1, 2008, July 31, 2008 and August 27, 2008; $260.65 for 60 units of Morphine Sulf 60 MG Tab SA dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; $27.75 for 60 units of Diazepam 5 MG Tablet dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; $480.05 for 210 units of Hydrocod/APAP 10/650 Tablet dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; and $113.44 for 30 units of Zaleplon 10 MG Capsule dispensed to Claimant on September 25, 2008 and October 21, 2008?

PARTIES PRESENT

Petitioner, (Healthcare Provider) Pharmacy ((Healthcare Provider)), appeared and was represented by HK, attorney. Respondent/Carrier, Texas Mutual Insurance Company, appeared and was represented by BJ, attorney. Claimant did not appear and his attendance was excused.

BACKGROUND INFORMATION

(Healthcare Provider) is an in-house pharmacy, providing medication to injured parties under workers’ compensation law for the rehabilitation facility, Functional Restoration Services. The following table serves to outline the overall dispute between (Healthcare Provider) and Carrier in this case:

Table 1

Date(s) of Service (DOS)

Medication / No. of Units

(Healthcare Provider) Charge to Carrier

Carrier Reimbursement to (Healthcare Provider)

Amount in Dispute

07/01/08

Sonata 10MG Capsule/30 units

$141.90

$17

$11.13

07/31/08

08/27/08

Sonata 10MG Capsule/30 units

$316.80

($158.40 x 2)

$261.54

($130.77 x 2 )

$55.26

($27.63 x 2)

07/01/08

07/31/08

08/27/08

09/25/08

10/21/08

Morphine Sulf 60 MG TAB SA/60 units

$1022.00 ($204.40 x 5)

$761.35

($17 x5)

$260.65

($52.13 x 5)

07/01/08

07/31/08

08/27/08

09/25/08

10/21/08

Diazepam 5 MG Tablet/60 units

$83.00

($16.60 x 5)

$55.25

($11.05 x 5 )

$27.75

($5.55 x 5)

07/01/08

07/31/08

08/27/08

09/25/08

10/21/08

Hydrocod/APAP 10/650 Tablet/210 units

$1213.50

($242.70 x 5)

$733.45

($146.69 x 5 )

$480.05

($96.01 x 5)

09/25/08

10/21/08

Zaleplon 10 MG Capsule/30 units

$289.00

($10 x 2)

$175.56

($87.78 x 2 )

$113.44

($56.72 x 2)

The evidence presented in the hearing indicated that the reimbursement Carrier provided to (Healthcare Provider) was based on Carrier’s calculation of a reasonable and customary fee for the medications.

After its request for reconsideration was denied by Carrier, (Healthcare Provider) requested relief through the Division’s Medical Fee Dispute Resolution (MFDR) section in order to obtain the remaining reimbursement totaling $948.28 from Carrier.

On January 14, 2011, the Division’s MFDR Officer issued a decision (“Medical Fee Dispute Resolution Findings and Decision” or MFDRFD) holding that (Healthcare Provider) was not entitled to additional reimbursement at issue from Carrier. The rationale behind the decision was that the Division was not provided with sufficient evidence to substantiate (Healthcare Provider)’ usual and customary (U&C) charge for the medications at issue. Following the adverse decision from MFDR, (Healthcare Provider) requested a medical contested case hearing to resolve the fee question in this case.

An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. (Texas Labor Code §408.021). The term "health care" includesa prescription drug, medicine, or other remedy. (Texas Labor Code §401.011(19)(E)). The commissioner of the Division of Workers’ Compensation is directed by statute to adopt a fee schedule for pharmacy and pharmaceutical services that will provide reimbursement rates that are fair and reasonable; assure adequate access to medications and services for injured workers; and minimize costs to employees and insurance carriers. (Texas Labor Code §408.028(f)). Insurance carriers must reimburse for pharmacy benefits and services using the fee schedule or at rates negotiated by contract. (Texas Labor Code §408.028(g)). The commissioner has adopted reimbursement methodology to establish the maximum allowable reimbursement (MAR) for prescription drugs in Rule 134.503.

Pursuant to Rule 134.503, the MAR for prescription drugs is the lesser of the provider’s U&C charge for the same or similar service or a fee established by formulas based on the average wholesale price (AWP) determined by utilizing a nationally recognized pharmaceutical reimbursement system such as Redbook or First DataBank Inc. in effect on the day the prescription drug was dispensed. For generic drugs, the formula is AWP per unit multiplied by the number of units multiplied by 1.25, plus a $4.00 dispensing fee. For brand name drugs, the formula is AWP per unit multiplied by the number of units multiplied by 1.09, plus a $4.00 dispensing fee. See Rule 134.503(a)(2) The evidence presented in the hearing revealed that the prescription medications at issue in this care are generic drugs except for Sonata that is a brand name drug. There is no contract between (Healthcare Provider) and Carrier, so Rule 134.503(a)(3) does not apply to the facts of this case.

On December 11, 2003, RR, the Executive Director of the Texas Workers’ Compensation Commission, issued Advisory 2003-21 to address the determination of a pharmacy’s U&C charge for prescription drugs. In part, the Advisory states:

The Commission’s pharmacy prescription pricing rule is based, in part, on several important provisions concerning health care provider charges. First, fee guidelines are based, in part, on a provision that payment may not be in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual’s behalf (Texas Labor Code Section 413.011(d)). Also, “[a] health care provider commits an offense if the person knowingly charges an insurance carrier an amount greater than that normally charged for similar treatment to a payor outside the workers’ compensation system, except for mandated or negotiated charges” (Texas Labor Code §413.043(a)).

Parties requesting medical dispute resolution should ensure that they abide by the statute and rule references outlined above. The Commission’s Medical Dispute Resolution Section has indicated that parties filing a dispute have the burden of proof to support their position for advocating additional reimbursement. The burden of proof includes production of sufficient evidence to support that the reimbursement requested is in accordance with the factors listed in §413.011(b) of the Texas Workers’ Compensation Act.

(Healthcare Provider) has the burden to establish its entitlement to the additional reimbursement it seeks. (Healthcare Provider)’ pharmacy manager, TH, provided an affidavit that was admitted into evidence. Mr. H’s April 29, 2011 affidavit indicates that (Healthcare Provider) makes no distinction between AWP and its U&C charges to avoid any discrepancy. (Healthcare Provider) also furnished literature and pricing information from RX30, a professional billing and pricing hardware and software program that (Healthcare Provider) utilizes. The evidence included an e-mail from MP, an employee of RX30, who indicated that RX30 does not calculate AWP itself, but, rather, it obtains current average wholesale pricing information for medications from First DataBank, Inc., a nationally recognized pharmaceutical reimbursement system. Ms. P’s e-mail indicated that AWPs may vary if sources other than First DataBank, Inc. are used.

With regard to Sonata 10 MG Capsule, dispensed on July 1, 2008, (Healthcare Provider) presented from the RX30 computer program that the AWP for this medication on July 1, 2008 was 4.21712. As illustrated in the table on page 2, above, the amount (Healthcare Provider) charged Carrier for 30 units of the medication was $141.90 for the date of service of July 1, 2008.

The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(B) for this medication for 30 units:

$4.21712 (AWP) x 30 (# of Units) x 1.09 + $4.00 (dispensing fee) = $141.8998 (rounded to $141.90)

The evidence, particularly the (Healthcare Provider) dispensing records for July 1, 2008 for this medication, was persuasive in showing that (Healthcare Provider)’ U&C charge for this medication is the same as the amount elicited from Rule 134.503(a)(2)(B) formula calculation. Therefore, the evidence indicated that (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $11.13 for the amount billed for Sonata 10 MG Capsule (30 units) dispensed on July 1, 2008.

With regard to Sonata 10 MG Capsule, dispensed on July 31, 2008 and August 27, 2008, (Healthcare Provider) presented evidence from the RX30 computer program that the AWP for this medication on the dispensed dates was 4.72171. As illustrated in the table on page 2, above, the amount (Healthcare Provider) charged Carrier for 30 units of the medication was $158.40.

The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(B) for this medication for 30 units:

$4.72171 (AWP) x 30 (# of Units) x 1.09 + $4.00 (dispensing fee) = $158.3999 (rounded to $158.40)

The evidence, particularly the (Healthcare Provider) dispensing records for the period from July 1, 2008 through August 27, 2008 for this medication, was persuasive in showing that (Healthcare Provider)’ U&C charge for this medication is the same as the amount elicited from Rule 134.503(a)(2)(B) formula calculation. Therefore, the evidence indicated that (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $55.26 for the amount billed for Sonata 10 MG Capsule (30 units) dispensed on July 31, 2008 and August 27, 2008.

With regard to Morphine Sulf 60 MG Tab SA (Healthcare Provider) Pharmacy presented evidence from the RX30 computer program that the AWP for this medication on the dates dispensed for July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008 was 3.3061. As illustrated in the table on page 2, above, the amount (Healthcare Provider) charged Carrier for 60 units of the medication was $204.40.

The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(A) for this medication for 30 units:

$3.3061 (AWP) x 60 (# of Units) x 1.25 + $4.00 (dispensing fee) = $251.9575 (rounded up to $251.96)

It appears that (Healthcare Provider) actually charged Carrier a U&C amount ($204.40) that was less than the product of the Rule 134.503(a)(2)(A) MAR calculation. The dispensing records from (Healthcare Provider) for this medication for the period from July 1, 2008 through October 31, 2008 were persuasive in establishing that its U&C charge for 60 units of the drug was $204.40 during the period at issue. Therefore, the evidence indicated that (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $260.65 for the amount billed for Morphine Sulf 60 MG Tab SA (60 units), dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008.

With regard to Diazepam 5 MG Tablet (Healthcare Provider) presented evidence from the RX30 computer program that the AWP for this medication on the dates at issue was 0.168. As illustrated in the table on page 2, above, the amount (Healthcare Provider) charged Carrier for 60 units of the medication was $16.60.

The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(A) for this medication for 60 units:

$0.168 (AWP) x 60 (# of Units) x 1.25 + $4.00 (dispensing fee) = $16.60

The dispensing records from (Healthcare Provider) for this medication for the period from July 1, 2008 October 31, 2008 were persuasive in establishing that its U&C charge for 60 units of the drug was $16.60 during the period at issue. The evidence showed that (Healthcare Provider)’ U&C charge for this medication is the same as the amount elicited from the Rule 134.503(a)(2)(A) MAR formula calculations. Therefore, as the evidence indicated, (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $27.75 for the amount billed for Diazepam 5 MG Capsule (60 units), dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008.

(Healthcare Provider) presented evidence from the RX30 computer program that the AWP for Hydrocodone/APAP 10/650 Tablet on the dispensing dates of July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008 was 0.9093. The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(A) for this medication:

$0.9093 (AWP) x 210 (# of Units) x 1.25 + $4.00 (dispensing fee) =$242.69125 (rounded down to $242.69)

The evidence, particularly the (Healthcare Provider) dispensing records for the period of July 1, 2008 through October 31, 2008 for this medication, was persuasive in showing that (Healthcare Provider)’s U&C charge for this medication is only $0.01 different as the amount elicited from the Rule 134.503(a)(2)(A) formula calculation. Therefore, as the evidence indicated, (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $1213.45 ($242.69 x 5) for Hydrocodone/APAP 10/650 (210 units) dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008.

With regard to Zaleplon 10 MG Capsule (Healthcare Provider) presented evidence from the RX30 computer program that the AWP for this medication on the dates at issue was 3.74667. As illustrated in the table on page 2, above, the amount (Healthcare Provider) charged Carrier for 30 units of the medication was $144.50.

The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(A) for this medication for 30 units:

$03.74667 (AWP) x 30 (# of Units) x 1.25 + $4.00 (dispensing fee) = $144.5001 (rounded down to $144.50)

The dispensing records from (Healthcare Provider) for this medication for the period from March 1, 2008 through November 30, 2008 were persuasive in establishing that its U&C charge for 30 units of the drug was $144.50 during the period at issue. The evidence showed that (Healthcare Provider)’ U&C charge for this medication is the same as the amount elicited from the Rule 134.503(a)(2)(A) MAR formula calculations. Therefore, as the evidence indicated, (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $113.44 for the amount billed for Zaleplon 10 MG Capsule (30 units), dispensed on September 25, 2008 and October 21, 2008.

Though the evidence indicated that (Healthcare Provider) did offer a discount to a very limited number of customers who pay for their medications in cash, the affidavit from Mr. H, dated April 1, 2011, persuasively explained that this amount was statistically insignificant (less than 0.0025%).

Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

  1. The parties present stipulated as follows:
  1. A.Venue is proper in the (City) East Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
    1. On (Date of Injury), Claimant was the employee of (Employer), and sustained a compensable injury.
    2. On (Date of Injury), Employer subscribed to a policy of workers’ compensation insurance through Texas Mutual Insurance Company.
    3. The medications for which additional reimbursement was sought in this case were dispensed as part of the medical care for the compensable injury of (Date of Injury).
    4. (Healthcare Provider) Pharmacy has no negotiated or contractual pharmacy fee agreement with Texas Mutual Insurance Company payable pursuant to Rule 134.503(a)(3).
    5. The preponderance of the evidence is not contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider) is entitled to reimbursement for the compensable injury of May 8, 1995 in the amount of $71.58 for 30 units of Celebrex 200 MG Capsule, dispensed on July 1, 2008, July 31, 2008, and August 27, 2008, which has been paid by the Carrier.
    6. The preponderance of the evidence is not contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider) is entitled to reimbursement for the compensable injury of May 8, 1995 in the amount of $198.56 for 90 units of Cyclobenzaprine 10 MG Tablet, dispensed on July 1, 2008, July 31, 2008, August 27, 2008 and September 25, 2008, which has been paid by the Carrier.
  2. Respondent delivered to Petitioner a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  3. The medications for which additional reimbursement was sought in this case were generic, except for Sonata that was brand name.
  4. On July 1, 2008 (Healthcare Provider) dispensed 30 units of Sonata 10 MG Capsule to Claimant for his compensable injury of May 8, 1995; (Healthcare Provider) billed Carrier a total of $141.90 for this medication.
  5. On July 31, 2008 and August 27, 2008 (Healthcare Provider) dispensed 30 units of Sonata 10 MG Capsule to Claimant for his compensable injury of May 8, 1995; (Healthcare Provider) billed Carrier a total of $316.80 ($158.40 x 2) for this medication.
  6. On July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008 (Healthcare Provider) dispensed 60 units of Morphine Sulf 60 MG Tablet SA to Claimant for his compensable injury of May 8, 1995; (Healthcare Provider) billed Carrier a total of $1022.00 ($204.40 x 5) for this medication.
  7. On July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008 (Healthcare Provider) dispensed 60 units of Diazepam 5MG Tablet to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $83.00 ($16.60 x 5) for this medication.
  8. On July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008 (Healthcare Provider) dispensed 210 units of Hydrocodone/APAP 10/650 Tablet to Claimant for his compensable injury of May 8, 1995; (Healthcare Provider) billed Carrier a total of $1,213.50 ($242.70 x 5) for this medication.
  9. On September 25, 2008 and October 21, 2008, (Healthcare Provider) dispensed 30 units of Zaleplon 10 MG Capsule to Claimant for his compensable injury of May 8, 1995; (Healthcare Provider) billed Carrier a total of $289.00 ($144.50 x 2) for this medication.
  10. (Healthcare Provider) established the AWP of the prescription drugs at issue in this case on the dispensing dates in dispute by providing information from RX30, a professional billing and pricing hardware and software program. RX30 obtained this data from a nationally recognized pharmaceutical reimbursement system (First DataBank, Inc.).
  11. For the Sonata 10 MG Capsule, the AWP on July 1, 2008 was 4.21712 pursuant to the data furnished by RX30.
  12. For the Sonata 10 MG Capsule, the AWP on the dates of service in dispute (July 31, 2008 and August 27, 2008) was 4.72171 pursuant to the data furnished by RX30.
  13. For the Morphine Sulf 60 MG Tablet SA, the AWP on the dates of service in dispute (July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008) was 3.3061 pursuant to the data furnished by RX30.
  14. For the Diazepam 5 MG Tablet, the AWP on the dates of service in dispute (July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008) was 0.168 pursuant to the date furnished by RX30.
  15. For the Hydrocodone/APAP 10/650 Tablet, the AWP on the dates of service in dispute (July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008) was 0.9093 pursuant to the data furnished by RX30.
  16. For the Zaleplon 10 MG Capsule, the AWP on the dates of service in dispute (September 25, 2008 and October 21, 2008) was 3.74667 pursuant to the data furnished by RX30.
  17. (Healthcare Provider)’ U&C charge for 30 units of Sonata 10 MG Capsule for July 1, 2008 was $141.90.
  18. (Healthcare Provider)’ U&C charge for 30 units of Sonata 10 MG Capsule on July 31, 2008 and August 27, 2008 was $158.40.
  19. (Healthcare Provider)’ U&C charge for 60 units of Morphine Sulf 60 MG Tablet SA, on the dates of service in dispute (July 1, 2008, July 31, 2008, August 27, 2008, September 225, 2008 and October 21, 2008) was $204.40.
  20. (Healthcare Provider)’ U&C charge for 60 units of Diazepam 5 MG Tablet on the dates of service in dispute (July 1, 2008, July 31, 2008, August 27, 2008, September 225, 2008 and October 21, 2008) was $16.60.
  21. (Healthcare Provider)’ U&C charge for 210 units of Hydrocodone/APAP 10/650 Tablet on the dates of service in dispute (July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008) was $242.70.
  22. (Healthcare Provider)’ U&C charge for 30 units of Zaleplon 10 MG Capsule on the dates of service in dispute (September 25, 2008 and October 21, 2008 was $144.50.
  23. For the Sonata 10 MG Capsule, dispensed on July 1, 2008 Carrier reimbursed (Healthcare Provider) a total of $130.77.
  24. For the Sonata 10 MG Capsule, dispensed on July 31, 2008 and August 27, 2008 Carrier reimbursed (Healthcare Provider) a total of $261.54 ($130.77 x 2).
  25. For the Morphine Sulf 60 MG Tablet SA, dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 225, 2008 and October 21, 2008 Carrier reimbursed (Healthcare Provider) a total of $761.35 ($152.27 x 5).
  26. For the Diazepam 5 MG Tablet, dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 225, 2008 and October 21, 2008 Carrier reimbursed (Healthcare Provider) a total of $55.25 ($11.05 x 5).
  27. For the Hydrocodone/APAP 10/650 Tablet, dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008, Carrier reimbursed (Healthcare Provider) a total of $733.45 ($146.69 x 5).
  28. For the Zaleplon 10 MG Capsule, dispensed on September 25, 2008 and October 21, 2008, Carrier reimbursed (Healthcare Provider) a total of $175.56 ($87.78 x 2).
  29. The MAR for 30 units of Sonata 10 MG Capsule, dispensed on July 1, 2008, was $141.90 which is equal to the amount elicited from the Rule 134.503(a)(2)(B) formula calculation.
  30. The MAR for 30 units of Sonata 10 MG Capsule, dispensed on July 31, 2008 and August 27, 2008 was $158.40 which is equal to the amount elicited from the Rule 134.503(a)(2)(B) formula calculation.
  31. The MAR for 60 units of Morphine Sulf 60 MG Tablet SA, dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008 was $204.40 which is less than the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  32. The MAR for 60 units of Diazepam 5 MG Tablet, dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008 was $16.60 which is equal to the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  33. The MAR for 210 units of Hydrocodone/APAP 10/650 Tablet, dispensed on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008 and October 21, 2008 was $242.69 which is less than (Healthcare Provider)’s U& C charge.
  34. The MAR for 30 units of Zaleplon 10 MG Capsule, dispensed on September 25, 2008 and October 21, 2008 was $144.50 which is equal to the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.

CONCLUSIONS OF LAW

  1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
  2. Venue is proper in the (City) Field Office.
  3. The preponderance of the evidence is contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider) Pharmacy is not entitled to additional reimbursement in the amount of $11.13 for 30 units of Sonata 10 MG Capsule dispensed to Claimant on July 1, 2008; $55.26 for 30 units of Sonata 10 MG Capsule dispensed to Claimant on July 31, 2008 and August 27, 2008; $260.65 for 60 units of Morphine Sulf 60 MG Tab SA dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; $27.75 for 60 units of Diazepam 5 MG Tablet dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; $480.00 for 210 units of Hydrocod/APAP 10/650 Tablet dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; and $113.44 for 30 units of Zaleplon 10 MG Capsule dispensed to Claimant on September 25, 2008 and October 21, 2008.

DECISION

(Healthcare Provider) Pharmacy is entitled to additional reimbursement in the amount of $11.13 for 30 units of Sonata 10 MG Capsule dispensed to Claimant on July 1, 2008; $55.26 for 30 units of Sonata 10 MG Capsule dispensed to Claimant on July 31, 2008 and August 27, 2008; $260.65 for 60 units of Morphine Sulf 60 MG Tab SA dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; $27.75 for 60 units of Diazepam 5 MG Tablet dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; $480.00 for 210 units of Hydrocod/APAP 10/650 Tablet dispensed to Claimant on July 1, 2008, July 31, 2008, August 27, 2008, September 25, 2008, and October 21, 2008; and $113.44 for 30 units of Zaleplon 10 MG Capsule dispensed to Claimant on September 25, 2008 and October 21, 2008.

ORDER

Carrier is liable for the additional reimbursement at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

The true corporate name of the insurance carrier is TEXAS MUTUAL INSURANCE COMPANY and the name and address of its registered agent for service of process is

RON WRIGHT, PRESIDENT

TEXAS MUTUAL INSURANCE COMPANY

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723

Signed this 28th day of June, 2011.

Judy L.Ney
Hearing Officer

End of Document
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