HB 18 — An Act amending the act of June 2, 1915 (P.L.736, No.338), known as the Workers' Compensation Act, in liability and compensation, further providing for prescription drugs and the treatment of work-related injuries; and, in procedure, further providing for peer review.

PRIOR PRINTER'S NO.

463 PRINTER'STHE NO.GENERAL ASSEMBLY OF PENNSYLVANIA HOUSE BILL Session of No.

2014 THE GENERAL ASSEMBLY OF PENNSYLVANIA HOUSE BILL Session of No.

HARRIS, HEFFLEY, MILLARD, TOPPER,SIMMONS IRVIN, SAYLOR AND GILLEN,TOPPER, FEBRUARY 13, 2017 ASREFERRED REPORTEDTO FROM COMMITTEE ON LABOR AND INDUSTRY, HOUSEFEBRUARY OF13, REPRESENTATIVES, AS AMENDED, JUNE 14, 2017 AN ACT AmendingAmereenacted the act of June 2, 1915 (P.L.736, No.338), entitled, as <-- reenacted and amended, "An act defining the liability of ananas employer to pay damages for injuries received by an employe schedulein the course of compensation;employment;

establishing an elective schedule of compensation;

Section 306(f.1)(3)(vi) of the act of June 2, 1915 <-- (P.L.736, No.338), known as the Workers' Compensation Act, is amended by adding a provision and paragraph (6) is amended by adding a subclause to read:

SECTION 1.

SECTION 306(F.1)(6)(II) OF THE ACT OF JUNE 2, <-- 1915 (P.L.736, NO.338), KNOWN AS THE WORKERS' COMPENSATION ACT, IS AMENDED, PARAGRAPH (3)(VI) IS AMENDED BY ADDING A SUBCLAUSE AND PARAGRAPH (6) IS AMENDED BY ADDING A SUBPARAGRAPH TO READ:

(I) Within thirty (30) days of the effective date of this provisionprovision, SUBCLAUSE, the department shall solicit public <-- comments regarding the selection of a prescription drug formulary under this provision.

<--The DURINGdepartment THEshall PUBLICpublish COMMENTnotice PERIOD,of THEthe DEPARTMENTpublic SHALLcomment CONDUCTperiod <--in ATthe LEASTPennsylvania ONEBulletin. PUBLIC HEARING ON THE SELECTION OF A DRUG FORMULARY.

The(II) departmentWithin shallthirty publish(30) noticedays after close of the public comment period ANDunder PUBLICsubprovision HEARINGS(I), the department shall publish notice of its selection of a prescription drug formulary in the Pennsylvania Bulletin.

<--The (II)prescription Withindrug formulary shall take effect thirty (30) days after close of the publicpublication commentrequired periodby underthis subprovisionsubprovision. (I), the department shall publish notice of its selection of a THE prescription drug <-- formulary SELECTED in the Pennsylvania Bulletin.

(III) The <--department prescriptionshall drugensure formularythat shallthe takecurrent effectprescription thirtydrug (30)formulary ONEis <--available HUNDREDthrough EIGHTYits (180)publicly daysaccessible afterInternet thewebsite publicationfor requiredreference by thisphysicians subprovision.and the general public.

(III)(IV) INThe SELECTINGprescription Aof NATIONALLYdrugs RECOGNIZED,that EVIDENCE-BASEDis <--not PRESCRIPTIONconsistent DRUGwith FORMULARYor FORrecommended ADOPTION,by THEthe DEPARTMENTprescription SHALLdrug CONSIDERformulary THEselected FOLLOWINGby FACTORS:the department shall not be considered reasonable and necessary for the purposes of paragraph (6).

20170HB0018PN2014* * * (6) Except in those cases in which a workers' compensation judge asks for an opinion from peer review under section 420, 20170HB0018PN0463 - 2 - (A)disputes WHETHERas THEto FORMULARYreasonableness FOCUSESor ONnecessity MEDICALof TREATMENTtreatment SPECIFICby TOa WORKERS'health COMPENSATION.care provider shall be resolved in accordance with the following provisions:

(B)* WHETHER* THE* BASIS(v) FORThe THEdepartment FORMULARYshall ISapprove READILYonly APPARENTthose ANDutilization PUBLICLYreview AVAILABLE.organizations that it determines have obtained certification as a utilization review entity under section 2151 of the Insurance Company Law of 1921.

(C) WHETHER THE FORMULARY INCLUDES MEASURES TO AID IN MANAGEMENT OF OPIOID MEDICATIONS.

(D) WHETHER THE FORMULARY APPROPRIATELY LIMITS BOTH DURATION AND DOSAGE OF PRESCRIPTIONS.

(E) THE COST OF IMPLEMENTATION OF THE FORMULARY.

(IV) THE DEPARTMENT SHALL ANNUALLY REVIEW UPDATES ISSUED BY THE FORMULARY PUBLISHER TO THE SELECTED FORMULARY AND BY NOVEMBER 1 EACH YEAR SHALL SOLICIT PUBLIC COMMENTS REGARDING THE UPDATES PROPOSED FOR ADOPTION BY PUBLISHING NOTICE OF THE PROPOSED UPDATES AND A PUBLIC COMMENT PERIOD IN THE PENNSYLVANIA BULLETIN.

THE PUBLIC COMMENT PERIOD FOR UPDATES TO THE ADOPTED FORMULARY SHALL BE AT LEAST TWENTY (20) DAYS, BUT NOT MORE THAN THAN THIRTY (30) DAYS.

WITHIN THIRTY (30) DAYS AFTER THE CLOSE OF THE PUBLIC COMMENT PERIOD, THE DEPARTMENT SHALL PUBLISH NOTICE OF THE ADOPTED UPDATES IN THE PENNSYLVANIA BULLETIN.

THE PUBLISHED UPDATES SHALL TAKE EFFECT THIRTY (30) DAYS AFTER THE PUBLICATION REQUIRED BY THIS SUBPROVISION.

(III) (V) The department shall ensure that the current <-- prescription drug formulary is available through its publicly accessible Internet website for reference by physicians and the general public.

(IV) (VI) The PRESCRIPTION OF DRUGS THAT IS CONSISTENT WITH <-- OR RECOMMENDED BY THE PRESCRIPTION DRUG FORMULARY SHALL BE CONSIDERED REASONABLE AND NECESSARY FOR THE PURPOSES OF PARAGRAPH (6).

EXCEPT IN CASES OF MEDICAL NECESSITY UNDER SUBPROVISION (VII), THE prescription of drugs that is not 20170HB0018PN2014 - 3 - consistent with or recommended by the prescription drug formulary selected by the department shall not be considered reasonable and necessary for the purposes of paragraph (6).

(VII) THE PRESCRIPTION OF DRUGS THAT IS NOT CONSISTENT WITH <-- OR RECOMMENDED BY THE PRESCRIPTION DRUG FORMULARY MAY ONLY BE CONSIDERED REASONABLE AND NECESSARY FOR THE PURPOSES OF PARAGRAPH (6) IF THE TREATING HEALTH CARE PROVIDER HAS SUBMITTED DOCUMENTATION OF MEDICAL NECESSITY, INCLUDING EVIDENCE-BASED ANALYSIS OF THE REASON FOR THE EXCEPTION, TO THE INSURER OR SELF-INSURED EMPLOYER AT THE TIME OF THE INITIAL PRESCRIPTION.

THE DOCUMENTATION OF MEDICAL NECESSITY SHALL BE ON A FORM PRESCRIBED BY THE DEPARTMENT.

(VIII) WITHIN EIGHTEEN (18) CALENDAR MONTHS FOLLOWING THE EFFECTIVE DATE OF THE PRESCRIPTION DRUG FORMULARY SELECTED UNDER THIS SUBCLAUSE, THE PENNSYLVANIA COMPENSATION RATINGS BUREAU SHALL CALCULATE THE SAVINGS ACHIEVED THROUGH THE IMPLEMENTATION OF THE PRESCRIPTION DRUG FORMULARY.

FOR THE CALENDAR YEAR IMMEDIATELY FOLLOWING THIS CALCULATION, THE AMOUNT OF SAVINGS SHALL BE USED TO PROVIDE AN IMMEDIATE REDUCTION IN RATES, EQUAL TO THE SAVINGS, APPLICABLE TO EMPLOYERS' WORKERS' COMPENSATION POLICIES.

* * * (6) Except in those cases in which a workers' compensation judge asks for an opinion from peer review under section 420, disputes as to reasonableness or necessity of treatment by a health care provider shall be resolved in accordance with the following provisions:

* * * (II) THE DEPARTMENT SHALL ASSIGN A REQUEST FOR UTILIZATION <-- REVIEW TO A UTILIZATION REVIEW ORGANIZATION AT RANDOM.

THE 20170HB0018PN2014 - 4 - UTILIZATION REVIEW ORGANIZATION SHALL ISSUE A WRITTEN REPORT OF ITS FINDINGS AND CONCLUSIONS WITHIN THE TIME FRAME REQUIRED BY THE NATIONALLY RECOGNIZED ACCREDITATION STANDARDS ADOPTED BY THE DEPARTMENT UNDER SUBPARAGRAPH (V).

IN NO CASE SHALL THE REPORT OF FINDINGS AND CONCLUSIONS BE ISSUED MORE THAN THIRTY (30) DAYS AFTER THE RECEIPT OF A REQUEST.

* * * (v) The department shall approve only those utilization review organizations that it determines have obtained certification as a utilization review entity under section 2151 <-- of the Insurance Company Law of 1921.

OR ACCREDITATION BY A <-- NATIONALLY RECOGNIZED ORGANIZATION WITH CERTIFICATION OR ACCREDITATION STANDARDS APPROPRIATE FOR RESOLVING UTILIZATION ISSUES FOR WORKERS' COMPENSATION PROGRAMS.

THE FOLLOWING SHALL APPLY:

(A) WITHIN THIRTY (30) DAYS OF THE EFFECTIVE DATE OF THIS CLAUSE, THE DEPARTMENT SHALL PUBLISH NOTICE IN THE PENNSYLVANIA BULLETIN OF THE SPECIFIC NATIONALLY RECOGNIZED CERTIFICATION OR ACCREDITATION THAT WILL BE REQUIRED IN ORDER TO BE APPROVED AS A UTILIZATION REVIEW ORGANIZATION.

(B) UPON PUBLICATION UNDER SUBCLAUSE (A), AN ENTITY WITHOUT THE APPROPRIATE CERTIFICATION OR ACCREDITATION MAY NOT ENGAGE IN UTILIZATION REVIEW UNDER THIS ACT, EXCEPT THAT AN ENTITY APPROVED AS A UTILIZATION REVIEW ORGANIZATION BY THE DEPARTMENT PRIOR TO THE EFFECTIVE DATE OF THIS CLAUSE MAY CONTINUE TO ENGAGE IN UTILIZATION REVIEW FOR UP TO EIGHTEEN (18) CALENDAR MONTHS AFTER THE PUBLICATION OF NOTICE UNDER SUBCLAUSE (A).

IF THE DEPARTMENT DETERMINES THAT AN ENTITY APPROVED AS A UTILIZATION REVIEW ORGANIZATION BY THE DEPARTMENT PRIOR TO THE EFFECTIVE DATE OF THIS CLAUSE IS ACTIVELY ATTEMPTING TO ACHIEVE 20170HB0018PN2014 - 5 - THE SELECTED CERTIFICATION OR ACCREDITATION, THE ENTITY SHALL NOT BE REQUIRED TO APPLY FOR REAUTHORIZATION DURING THE EIGHTEEN-MONTH PERIOD.