maps of jurisdictional laws and regulations...jurisdictional laws and regulations january 2020 2...
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Maps of jurisdictional laws and regulationsJANUARY 2020
2Confidential property of Optum.
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Jurisdictional generic medication mandates
DAW = Dispense as Written DNS = Do Not Substitute Data – Reflects published state workers’ compensation statutes/regulations on generic dispensing. *Indicates injured worker can pay difference between brand and generic when brand dispensed without proper authorization. Current as of January 2020.
WA
OR*
CA
NV
ID
MT*
WY*
COUT
NMAZ
TX*
OK
KS
NE
SD
ND* MN
WI*
IL
IA
MO
AR
LA
AL
TN*
MIPA
NY
VT*
GA
FL*
MS
KY*
SC
NC
MDOH* DEIN WV*
NJCT
MA
ME*
RI
VA
NH
AK*
DC
HI
Substitution mandated
Substitution mandated except where prescriber notate DAW, DNS or similar
Substitution mandated except where written statement of medical necessity, prior authorization or other requirement provided/met
Substitution not specifically mandated for workers’ compensation
3Confidential property of Optum.
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Use of original NDC for repackaged drugs
*Additional regulatory/statutory factors and qualifications may apply. Data – Reflects published statutes/regulations/case law on usage of underlying NDC for repackaged drugs. Current as of July 2020.
Mandates use of original NDC for billing and/or reimbursement
No mandate for use of original NDC for billing/reimbursement
WA*
OR
CA
NV
ID
MT
WY
COUT
AZ
TX
OK
KS
NE
SD
ND MN
WI
IL*
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL*
MS
KY
SC
NC
MDOH DE
IN WV
NJCT
ME
RI*
VA
AK
DC
HI
MANH
NM
4Confidential property of Optum.
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Durable medical equipment and supplies state fee schedule
FS = Fee Schedule MAR = Maximum Allowable Reimbursement | U&C = Usual & Customary Charge | Note – Categories represent interpretation of state requirements. Some states use tiered/multiple levels of reimbursement. Data – Reflects published State Fee Schedules. Current as of January 2020.
WA
OR
CA
NV
ID
MT
WY
COUT
NMAZ
TX
OK
KS
NE
SD
ND MN
WI
IL
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL
MS
KY
SC
NC
MDOH DE
IN WV
NJCT
MA
ME
RI
VA
NH
AK
DC
HI
State-established MAR
Medicare allowable (may be +/- percentage markup)
State Medicaid allowable
Provider cost and/or invoice amount + markup
U&C or reasonable amount
Provider billed charge (may be +/- percentage markup)
Not regulated or addressed/no specific Fee Schedule established
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Physician dispensing/repackaging restrictions
Note – States such as AR, DE, FL, KY, NY, and TN have overlapping workers’ compensation and state Practice Act controls. Data – Reflects published state statutes/regulations/case law on Physician Dispensing/Repackaging. Current as of January 2020.
WA
OR
CA
NV
ID
MT
WY
COUT
NMAZ
TX
OK
KS
NE
SD
ND MN
WI
IL
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL
MS
KY
SC
NC
MDOH DE
IN WV
NJCT
MA
ME
RI
VA
NH
AK
DC
HI
Workers’ compensation statutes/regulations limit physician dispensing and/or repackaging (restrictions on dispensing, billing and/or reimbursement).
Legal restrictions (Practice Act) in addition to workers’ compensation controls
Legal restrictions on physician dispensing (Practice Act)
No clear legal or workers’ compensation limits on physician dispensing and/or repackaging
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Initial opioid prescribing limits
Data – Reflects Legislation/Regulation enacting initial opioid prescribing limitations. Note – Initial days supply limitations can vary across jurisdictions and treatment facilities. Current as of January 2020.
WA
OR
CA
NV
ID
MT
WY
COUT
NMAZ
TX
OK
KS
NE
SD
ND MN
WI
IL
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL
MS
KY
SC
NC
MDOH DE
IN WV
NJCT
MA
ME
RI
VA
NH
AK
DC
HI
2019 Policy enacted
2018 Policy enacted
2017 Policy enacted
2016 Policy enacted
No recent limitation policy action
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Pharmacy direction of care
Note – Categories set according to statute/regulation/case law relating to direction of care for pharmacy benefit/medical provider networks. Does not reflect dispensing physicians. Current as of January 2020.
WA
OR
CA
NV
ID
MT
WY
COUT
NMAZ
TX
OK
KS
NE
SD
ND MN
WI
IL
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL
MS
KY
SC
NC
MDOH DE
IN WV
NJCT
MA
ME
RI
VA
NH
AK
DC
HI
Permitted under statute/regulatory conditions
Potentially permitted withrestrictions or qualifications
Statute/regulation silent or unclear
Prohibited by statute/regulation
8Confidential property of Optum.
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Compounded medication regulations
*Additional state regulatory/statutory billing and payment requirements which may include prior authorization. Data – Reflects published statutes/regulations/fee schedules related to workers’ compensation compounded medication billing/reimbursement. Current as of January 2020.
WA*
OR
CA*
NV*
ID
MT*
WY*
COUT
NMAZ
TX*
OK*
KS*
NE
SD
ND* MN
WI
IL
IA
MO
AR*
LA
AL
TN*
MI* PA
NY*
VT
GA*
FL*
MS*
KY*
SC
NC
MDOH* DEIN* WV
NJCT
MA
ME
RI*
VA
NH
AK*
DC
HI
Not addressed by specific WC regulations/fee schedules
Unique state compounded medications reimbursement/billing qualifiers and/or provisions
Individual ingredient(s) NDC required on compounded medications bills
Language explicitly permits denial of reimbursement for individual ingredients lacking an NDC
9Confidential property of Optum.
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eBilling regulations
Note – Map reflects eBilling mandates inclusive of all workers’ compensation medical and pharmacy services. Data – Reflects published statutes/regulations requiring eBilling or published implementation guides with an eBilling effective date. Current as of January 2020.
WA
OR
CA
NV
ID
MT
WY
COUT
NMAZ
TX
OK
KS
NE
SD
ND MN
WI
IL
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL
MS
KY
SC
NC
MDOH DE
IN WV
NJCT
MA
ME
RI
VA
NH
AK
DC
HI
Regulations adopted but notmandated on providers
eBilling not mandated
Mandated on providers/payers
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Medical marijuana
Source: ProCon.org *Includes workers’ comp fee schedule reimbursement for medical marijuana. Current as of January 2020.
WA
OR
CA
NV
ID
MT
WY
COUT
NM*AZ
TX
OK
KS
NE
SD
ND MN
WI
IL
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL
MS
KY
SC
NC
MDOH DE
IN WV
NJCT
MA
ME
RI
VA
NH
AK
DC
HI
Medical use of marijuana currently prohibited with legalized usage of cannabidiol (CBD) for limited purposes
Legalized medical marijuana
Legalized recreational and medical marijuana
Medical use of marijuana currently prohibited
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Workers’ compensation medication formularies
* Arizona technically adopted the ODG formulary along with their medical treatment guidelines; however, preauthorization is not required. Delaware also adopted a “preferred drug list” or PDL.Current as of January 2020
Current formulary
Have discussed formulary
States with no formulary
WA
OR
CA
NV
ID
MT
WY
COUT
NMAZ*
TX
OK
KS
NE
SD
ND MN
WI
IL
IA
MO
AR
LA
AL
TN
MIPA
NY
VT
GA
FL
MS
KY
SC
NC
MDOH DE*
IN WV
NJCT
MA
ME
RI
VA
NH
AK
DC
HI