Pennsylvania legislature considering pain treatment guidelines for workers’ compensation claims

by | Jun 15, 2018

In response to a recent veto of Senate Bill 936 (workers’ comp formulary legislation), the Pennsylvania Legislature has taken up new efforts to establish opioid utilization and treatment controls for workers’ compensation claims. These efforts, which are currently drafted in Senate Bill 1187, call for developing guidelines for prescribing opioids and other potentially addictive medications to injured workers.

The bill also contains clarification on reimbursement for compounded medications, tying to the existing fee schedule utilizing the original manufacturer’s NDC of each ingredient, and creates requirements for certification/accreditation of utilization review organizations in Pennsylvania.

Creation of prescribing and treatment guidelines
The bill (as introduced) requires the Department of Labor and Industry (the department), in consultation with other agencies, to develop evidence-based guidelines appropriate for prescribing pain medications for treatment of work-related injuries. The guidelines shall address type, dosage and duration of opioids and other pain medications recognized as potentially addictive.

The bill requires a public comment period, with built-in timelines, that includes at least three public hearings. Within 30 days after close of the public comment period, the department is to publish the guidelines which are to apply to any prescription of pain medication drugs for treatment of work-related injuries made after 30 days from date of that publication.

In developing the guidelines, the department is to consider several key factors including:

  • Assuring injured workers access to reliable, safe and effective prescription pain medications.
  • Appropriately limiting both duration and dosage of all prescribed pain medication drugs and including consideration of treatment options beyond prescription of pain medication drugs.
  • Including measures to aid in managing pain medications, specifically including opioid medications.

Once the guidelines are established, drugs consistent with or recommended by the guidelines are to be considered reasonable and necessary. Prescription of drugs not consistent with guidelines will be considered reasonable and necessary if the prescribing physician has submitted documentation explaining their medical necessity to the insurer (at time of initial prescription). An insurer will be required to accept the prescription unless it is determined not to be reasonable and necessary by a utilization review organization.

While we generally support many facets of the bill, including development of treatment guidelines related to opioids, the bill is certain to take many twists and turns during the legislative process before being delivered as a final outcome. The Optum Government Affairs team will continue to monitor developments surrounding this bill and work to assist policy makers as needed.

Official information on SB 1187 can be found here. Should you have any questions on this bill or other public policy issues, please feel free to contact our Government Affairs Team at

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