PA Act 184: Workers' Compensation/Prescription Reimbursement Reform Effective December 26, 2014
Act 184 includes a number of provisions regarding physician-prescribed medications/controlled substances and associated reimbursement, including:
- Physician-dispensed medications will now be subject to the reimbursement cap of 110 perecent of the average wholesale price of prescriptions in the same fashion as prescriptions from pharmacies.
- In order to be eligible for reimbursement, the original drug manufacturer’s National Drug Code number must now be included on all bills.
- Physician-prescribed controlled substances (such as hydrocodone) will be limited to one seven-day supply beginning upon the injured worker’s initial treatment date with the healthcare provider in question. However, to the extent the injured employee undergoes a medical procedure or surgery (not necessarily performed by the provider in question), an additional fifteen-day supply may be dispensed effective as of the date of the procedure. Physicians are limited to dispensing an initial thirty-day supply of any other medication.
- All providers, other than licensed pharmacies, are prohibited from seeking reimbursement for over-the-counter medication.
Act 184 eliminates the following:
- The ability of the injured worker to seek medications from numerous/various healthcare providers. The limitations set forth in Act 184 apply to all physicians and not just to each individual provider/treater.
- Substantial profit/markup by treating physicians when prescribing medications by eliminating the “repackaging” tool used by many treating physicians.
Act 184 became effective on December 26, 2014 and will apply only to medications prescribed on and after December 26, 2014.
Disclaimer: this E-Flash does not offer specific legal advice, nor does it create an attorney-client relationship. You should not reach any legal conclusions based on the information contained in this E-Flash without first seeking the advice of counsel.