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You are here: Home . wc . news . advisories . ad2004-04

ADVISORY 2004-04

SUBJECT: Implementation of Amended Pharmacy Rules 134.503 and 134.504

In compliance with Texas Labor Code §408.028(e) (added by the 78th Texas Legislature in House Bill 833), the Commission has adopted amendments to Rules 134.503 and 134.504 that allow an injured employee to obtain a brand name drug at their own expense rather than accept a generic drug or over-the-counter alternative that has been prescribed for their compensable injury. The statute and amended rules provide a means for the employee to be responsible for paying the difference between the cost of the brand name drug and the cost of the generic drug. The statute and amended rules also provide that an employee may not seek reimbursement for the difference in cost from an insurance carrier. In addition, the injured employee is not entitled to use the medical dispute resolution provisions of Chapter 413 of the Texas Workers' Compensation Act with regard to the amount charged by the health care provider.

Revised Form TWCC-66
The TWCC-66 (Statement of Pharmacy Services) has been revised to reflect the requirements of the amended pharmacy rules. The revised form is available on the Commission web site at www.tdi.texas.gov. Pharmacists must use the revised TWCC-66 (dated 04/01/04) immediately when an injured employee chooses to obtain a brand name drug at their own expense. The Commission recognizes that reprogramming billing systems may take several months. Therefore, the previous version of the TWCC-66a (dated 01/01/03) may continue to be used, through October 31, 2004, for pharmacy bills other than when an injured employee chooses to obtain a brand name drug at their own expense. This previous form is also available on the Commission web site at www.tdi.state.tx.us. The revised TWCC-66 (dated 04/01/04) is required for all pharmacy bills submitted on or after November 1, 2004.

The amended form uses a number of check boxes. Some providers have indicated that they use "dot-matrix" printers that make the use of check boxes difficult. Therefore, providers may program the form into their system and simply place an "X" in a blank (rather than a box) if that is easier for them to reproduce, as long as the "X" is placed where the box would be if it were present.

The TWCC-66 is revised not only to implement amended Rules 134.503 and 134.504, but also to more closely align the commission's reporting requirements with those of the Healthcare Insurance Portability and Accountability Act (HIPAA). The commission is working with electronic submission trading partners to implement the International Association of Industrial Accident Boards and Commissions' (IAIABC) 837 medical billing format for TXCOMP.

Because of the need to standardize the medical billing format, the Commission will not be able to approve alternate TWCC-66 formats.

Signed this 3rd day of May, 2004

Richard F. Reynolds, Executive Director

Distribution:
TWCC Staff
Medical Professional Associations
Carrier Representatives
Forms Notification List
Public Information List
TWCC website



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