HLS 16RS-982 ORIGINAL
2016 Regular Session
HOUSE BILL NO. 725
BY REPRESENTATIVES BROADWATER, LANCE HARRIS, AND DAVIS
WORKERS COMPENSATION: Provides for the creation of a workers' compensation
closed pharmacy formulary
1 AN ACT
2To amend and reenact R.S. 23:1203.1(B), (D)(introductory paragraph), (E), (H), (I), (J)(1),
3 (L), and (M), relative to workers' compensation; to provide for the creation of a
4 closed pharmacy formulary; to provide for the criteria for the creation and content
5 of the formulary; to provide for variances; and to provide for related matters.
6Be it enacted by the Legislature of Louisiana:
7 Section 1. R.S. 23:1203.1(B), (D)(introductory paragraph), (E), (H), (I), (J)(1), (L),
8and (M) hereby amended and reenacted to read as follows:
9 ยง1203.1. Definitions; medical treatment schedule; medical advisory council; closed
10 pharmacy formulary
11 * * *
12 B. The director shall, through the office of workers' compensation
13 administration, promulgate rules in accordance with the Administrative Procedure
14 Act, R.S. 49:950 et seq., to establish a medical treatment schedule and a closed
15 pharmacy formulary.
16 (1) Such The medical treatment rules shall be promulgated.
17 (2) The medical treatment schedule shall meet the criteria established in this
18 Section and shall be organized in an interdisciplinary manner by particular regions
19 of the body and organ systems.
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1 (3) The closed pharmacy formulary shall be the most recent version of the
2 Workers' Compensation Formulary of the Official Disability Guidelines Appendix
3 A; Treatment in Workers' Comp, published by Work Loss Data Institute. The closed
4 pharmacy formulary shall only include the applicable portions of the particular
5 Official Disability Guidelines; Treatment in Workers' Comp guideline provisions
6 that are specific to the drugs in the formulary in Appendix A.
7 (4) The director shall promulgate the rules and regulations as are necessary
8 to implement the procedures relative to the closed pharmacy formulary. The rules
9 shall be promulgated and the formulary shall be adopted by July 1, 2017.
10 * * *
11 D. The medical treatment schedule and the closed pharmacy formulary shall
12 be based on guidelines which shall meet all of the following criteria:
13 * * *
14 E.(1) The medical advisory council shall develop guidelines in accordance
15 with Subsections C and D of this Section and may amend the schedule in accordance
16 with Subsection C and Paragraph (D)(2) of this Section before submission to the
17 director of the office of workers' compensation administration for initial and
18 subsequent formal adoption and promulgation in accordance with the Administrative
19 Procedure Act, R.S. 49:950, et seq.
20 (2) Prior to the adoption of the closed pharmacy formulary, the director shall
21 engage with employers, insurers, private sector employee representatives, public
22 sector employee representatives, treating physicians actively practicing medicine,
23 pharmacists, pharmacy benefit managers, attorneys who represent applicants, injured
24 workers, and any other stakeholder the director deems appropriate to facilitate the
25 development of the formulary.
26 * * *
27 H.(1) The director, with the assistance of the medical advisory council, is
28 authorized to review and update the medical treatment schedule no less often than
29 once every two years. Such updates shall be made by rules promulgated in
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HB NO. 725
1 accordance with the Administrative Procedure Act, R.S. 49:950 et seq. In no event
2 shall the schedule contain multiple guidelines covering the same aspects of the same
3 medical condition which are simultaneously in force.
4 (2) The closed pharmacy formulary shall be automatically updated with the
5 most recent version of the Workers' Compensation Formulary of the Official
6 Disability Guidelines Appendix A; Treatment in Workers' Comp, published by Work
7 Loss Data Institute, and the applicable portions of the particular Official Disability
8 Guidelines; Treatment in Workers' Comp guideline provisions that are specific to the
9 drugs in the formulary Appendix A. The Work Loss Data Institute shall provide the
10 director and the medical advisory council a list identifying any updates to the
11 formulary. The medical advisory council may recommend to the director that a
12 specific portion of the formulary or any subsequent updates be amended or not be
13 accepted upon a showing by the medical advisory council of higher ranking scientific
14 medical evidence. The director may, upon recommendation by the medical advisory
15 council, promulgate a rule in accordance with the Administrative Procedure Act not
16 to accept a specific portion of an update.
17 I. After the promulgation of the medical treatment schedule and the closed
18 pharmacy formulary, throughout this Chapter, and notwithstanding any provision of
19 law to the contrary, medical care, services, and treatment due, pursuant to R.S.
20 23:1203 et seq., by the employer to the employee shall mean care, services, and
21 treatment in accordance with the medical treatment schedule and the closed
22 pharmacy formulary. Medical care, services, and treatment that varies from the
23 promulgated medical treatment schedule or the closed pharmacy formulary shall also
24 be due by the employer when it is demonstrated to the medical director of the office
25 by a preponderance of the scientific medical evidence, that a variance from the
26 medical treatment schedule or the closed pharmacy formulary is reasonably required
27 to cure or relieve the injured worker from the effects of the injury or occupational
28 disease given the circumstances.
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HB NO. 725
1 J.(1) After a medical provider has submitted to the payor the request for
2 authorization and the information required by the Louisiana Administrative Code,
3 Title 40, Chapter 27, the payor shall notify the medical provider of their action on
4 the request within five business days of receipt of the request. If any dispute arises
5 after January 1, 2011, as to whether the recommended care, services, or treatment is
6 in accordance with the medical treatment schedule or the closed pharmacy
7 formulary, or whether a variance from the medical treatment schedule or the closed
8 pharmacy formulary is reasonably required as contemplated in Subsection I of this
9 Section, any aggrieved party shall file, within fifteen calendar days, an appeal with
10 the office of workers' compensation administration medical director or associate
11 medical director on a form promulgated by the director. The medical director or
12 associate medical director shall render a decision as soon as is practicable, but in no
13 event, not more than thirty calendar days from the date of filing.
14 * * *
15 L.(1) It is the intent of the legislature that, with the establishment and
16 enforcement of the medical treatment schedule and the closed pharmacy formulary,
17 medical and surgical treatment, hospital care, and other health care healthcare
18 provider services shall be delivered in an efficient and timely manner to injured
19 employees.
20 (2) The legislature further intends that injured workers shall receive the
21 necessary drugs, pharmaceutical products, and services, which aids employers and
22 insurers to offer more direct care as it relates to prescription drugs, pharmaceutical
23 products and services.
24 M.(1) With regard to all treatment not covered by the medical treatment
25 schedule or the closed pharmacy formulary promulgated in accordance with this
26 Section, all medical care, services, and treatment shall be in accordance with
27 Subsection D of this Section.
28 (2) Notwithstanding any other provision of this Chapter, all treatment not
29 specified in the medical treatment schedule and not found in Subsection D of this
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1 Section shall be due by the employer when it is demonstrated to the medical director,
2 in accordance with the principles of Subsection C of this Section, that a
3 preponderance of the scientific medical evidence supports approval of the treatment
4 that is not covered.
5 * * *
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 725 Original 2016 Regular Session Broadwater
Abstract: Provides for the creation of a closed pharmacy formulary for the treatment of
injured workers in workers' compensation claims.
Proposed law requires that rules shall be promulgated and the closed pharmacy formulary
be adopted by July 1, 2017.
Present law created the medical treatment guidelines.
Proposed law retains present law and provides a procedure for the creation of a closed
pharmacy formulary subject.
Proposed law requires that in the development of a pharmacy formulary, the director consult
with workers' compensation stakeholders for specialized input.
Present law requires that the director update the medical treatment guidelines every two
years.
Proposed law retains present law and provides that the pharmacy formulary will
automatically update with the most recent versions of the specific medical treatment
literature as provided in proposed law.
Present law provides that if the treatment needed by the injured worker is not sufficiently
addressed by the medical treatment guidelines, that the employer may demonstrate by
preponderance of the scientific medical evidence that a variance is necessary. Proposed law
retains present law and adds to this exception, along with the medical treatment guidelines,
that the pharmacy formulary will also be subject to a variance pursuant to the procedures in
present law.
Proposed law provides legislative intent that all injured workers are entitled to receive the
necessary drugs and services, with employers and insurers having the right to direct care.
(Amends R.S. 23:1203.1(B), (D)(intro. para.), (E), (H), (I), (J)(1), (L), and (M))
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