1

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

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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

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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

6Confidential property of Optum.

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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

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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