What the Hawaii Fee Schedule Covers
Hawaii's Department of Labor & Industrial Relations publishes an annual fee schedule that lists the maximum reimbursable amounts for prescription medications under worker's compensation. The schedule is updated each year to reflect changes in drug pricing, new therapies, and inflation. Employers pay a flat fee to the state for each prescription, and the employee receives the medication at no out‑of‑pocket cost, provided the drug is on the list and prescribed by a licensed medical provider.
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How the Fees Are Structured
The schedule is divided into three tiers: standard, specialty, and high‑cost specialty drugs. Standard drugs are common OTC or brand‑name medications with a capped reimbursement of $50–$150 per prescription. Specialty drugs, such as biologics or advanced biologic therapies, can cost $500–$3,000, while high‑cost specialty drugs can exceed $5,000 per dose. Each tier includes a maximum daily, weekly, or monthly cap to prevent runaway costs.
Example Table of Typical Caps
| Tier | Typical Cost Range | Reimbursement Cap |
|---|---|---|
| Standard | $50–$150 | $300 per month |
| Specialty | $500–$3,000 | $1,200 per month |
| High‑Cost Specialty | $5,000+ | $2,500 per month |
Eligibility and Documentation Requirements
To qualify, the medication must be prescribed by a licensed provider who has documented a legitimate medical necessity related to the workplace injury. The prescription must be filled in a Hawaii pharmacy and submitted with the worker's compensation claim. Employers must retain the prescription receipt and the provider's documentation for audit purposes.
Appealing a Denied Prescription Claim
If a prescription is denied, the employee can file an appeal within 30 days of the denial notice. The appeal must include the original prescription, a detailed medical justification, and any supporting test results. The state's workers' compensation appeals board will review the evidence and can overturn the denial if the medical necessity is proven.
Recent Updates and Trends
In 2024, Hawaii added several new biologic agents to the specialty tier, reflecting advances in treating chronic conditions such as rheumatoid arthritis and psoriasis. Employers should review the updated schedule annually to adjust their budgeting and ensure compliance. Additionally, the state has introduced a "pharmacy benefit manager" program to negotiate lower wholesale prices for high‑cost specialty drugs, potentially reducing reimbursements for employers while maintaining employee access.