CorVel is a national provider of industry leading workers’ compensation solutions to Montana payors. Incidents and injuries can be reported to our 24/7 call center, to the online claims system or via mobile apps. Reports are immediately processed by our proprietary rules engine where medical management begins immediately as needed, and the claim is assigned to a Claims Adjuster within one business day or less of initial receipt.
Our comprehensive return to work program ensures collaboration and communication with all interested parties including the injured worker, employer, human resources, medical and safety teams, and healthcare providers. We use technology, compassionate case management for employees and cost containment measures, to give Montana employers a superior program.
As a service to our clients, CorVel is providing links to information related to the COVID-19 pandemic provided by the states.
Legislature Status: Back in session after 2020 absence and interim committee meetings canceled.
SB 395 – Generally revise health insurance laws.
Issues: Workers’ Compensation (Prescription Drug Formulary)
This measure establishes licensure, reporting, marketing, and network adequacy requirements for Pharmacy Benefit Managers (PBMs).
A PBM must apply for licensure with the insurance commissioner. Each application must be accompanied by a nonrefundable fee of $1,000. The commissioner may refuse to issue or renew a license if the commissioner finds that the applicant: (a) is not competent, trustworthy, or financially responsible; (b) has violated the insurance laws of this state; or (c) has had an insurance or other certificate of authority or license denied or revoked for cause by any jurisdiction.
Prohibited PBM Practices
This measure provides that contracts between a PBM and pharmacies or pharmacists may not prohibit, restricted, or penalized in any way from disclosing to any enrollee any information the pharmacy or pharmacist considers appropriate regarding: (a) the decision of utilization reviewers or similar persons to
authorize or deny drug coverage or benefits; and (b) the process that is used to authorize or deny drug coverage or benefits. PBM contract’s may not limit, prohibit, restrict disclosure of information to the commissioner when the commissioner is investigating or examining a complaint or conducting a review of a pharmacy benefit manager’s compliance with this measure.
Marketing and Advertising
The commissioner can review complaints related to PBM marketing and advertising material to only when it is determined the materials violate this Act, Transparency to Carriers and Sponsors PBMs must disclosure with 45 days of request the following information to a carrier or plan sponsor:
(a) the aggregate WACs from a manufacturer or wholesale distributor for each therapeutic category of prescription drugs;
(b) the aggregate WACs from a manufacturer or wholesale distributor for each therapeutic category of prescription drugs available to enrollees;
(c) the aggregate amount of rebates received by the PBM by therapeutic category of prescription drugs;
(d) any other fees received from a manufacturer or wholesale distributor and the reason for the fees;
(e) whether the PBM has a contract, agreement, or other arrangements with a manufacturer to exclusively dispense or provide a drug to enrollees of the health carrier or plan sponsor, and the application of all consideration or economic benefits collected or received pursuant to the arrangement;
(f) prescription drug utilization information for enrollees of the health carrier or plan sponsor.
PBMs can require carriers or plan sponsors to agree to a nondisclosure agreement regarding the proprietary nature of the information above.
Transparency Report – Commisoner
Every July 1, for the immediately preceding year, PBMs must report to the state the following:
(a) the aggregate prescription drug spending for all of the PBMs health carriers and plan sponsor clients in the state;
(b) the aggregate prescription drug spending net of all rebates and other fees and payments, direct or indirect, from all sources;
(c) the aggregate dollar amount of all rebates that the PBM received from all manufacturers for all health carrier and plan sponsor clients in this state. The amount must include any utilization discounts the pharmacy benefit manager received from a manufacturer or wholesale distributor.
(d) the aggregate dollar amount of all fees from all sources, direct or indirect, that the pharmacy benefit manager received for all of the pharmacy benefit manager’s health carrier and plan sponsor clients in this state and the reason for the fees;
(e) the aggregate dollar amount of all retained rebates and fees that the pharmacy benefit manager received from all sources, direct or indirect, that were not passed through to health carrier and plan sponsor clients in this state;
(f) the aggregate retained rebate and fees percentage;
(g) the highest, lowest, and mean aggregate retained rebate and fees percentage for all of the PBMs health carrier and plan sponsor clients in this state; (h) deidentified claims-level information in an electronic format that allows the commissioner to sort and analyze.
Information that is provided to the state is confidential and not subject to disclosure.
This measure states that PBMs are to provide an adequate and accessible pharmacy network. The commissioner is to adopt rules for network adequacy standards that consider the relative availability of physical pharmacies in a geographic area.
340B Drug Pricing Program
This measure provides that carriers or PBMs may not:
(1) prohibit a federally certified health entity or a pharmacy under contract with an entity to provide pharmacy services from participating in the pharmacy benefit manager’s or health carrier’s provider network;
(2) reimburse a federally certified health entity or a pharmacy under contract with an entity differently than it reimburses other similarly situated pharmacies;
(3) require a claim for a drug to include a modifier to indicate that the drug is a 340B drug unless the claim is for payment, directly or indirectly, by the Medicaid program; or
(4) create a restriction or an additional charge on a patient who chooses to receive drugs from a federally certified health entity or a pharmacy under contract with an entity, including but not limited to a patient.
Most Recent Update:
5/12/2021 This measure was signed by Governor Greg Gianforte (R). The measure takes effect upon enactment.
HB 313 – Treating physician in workers’ compensation cases.
Issues: Workers’ Compensation (General), Workers’ Compensation (Direction Of Care)
This measure allows workers to choose their treating physician in workers’ compensation cases.
This measure provides that a worker may choose their treating physician in workers’ compensation cases for initial treatment and after initial treatment and diagnosis. The measure provides that an insurer may verify that the designated person agrees to carry out certain responsibilities related to workers’ compensation cases.
This measure dictates that the treating physician may be changed at any time with the consent of the worker and the insurer that has accepted liability for the claim. Refusal to consent to a change in a treating physician is subject to mediation.
This measure also specifies that if an injured worker accepts an insurer’s recommendation to use a managed care organization or a preferred provider organization as a treating physician, the insurer is not liable for medical services obtained outside of the recommendation by the managed care or provider organization.
Furthermore, this measure dictates that if the injured worker requires immediate emergency medical treatment for an occupational injury or disease, the insurer shall pay for the emergency medical treatment at 100% of the department’s fee schedule even if the emergency medical treatment is from a health care provider outside of the preferred provider organization.
Most Recent Update: This measure failed upon adjournment on April 26. This measure is ineligible for further consideration.
SB 83 – Relating to establishing allowable and prohibited practices for pharmacy benefit managers.
Issues: Workers’ Compensation (Prescription Drug Formulary)
A measure relating to pharmacy benefit manager or third-party payer fees, co-payment limitations, and prohibitions for pharmacists and pharmacies.
This measure dictates that a pharmacy benefit manager or third-party payer may not directly or indirectly charge or hold a pharmacy responsible for a fee related to a claim:
(a) if the fee is not apparent at the time the claim is processed;
(b) if the fee is not reported on the remittance advice of an adjudicated claim;
(c) after the initial claim is adjudicated; or
This measure also dictates that a pharmacy benefit manager or third-party payer may collect a performance-based fee from a pharmacy only if the pharmacy fails to meet the criteria established by a pharmacy performance measurement entity. The fee may be applied only to the professional dispensing fee outlined in the contract with the pharmacy and may not be imposed on the cost of goods sold by a pharmacy. For this purpose, only criteria established by a pharmacy performance measurement entity may be used to measure a pharmacy’s performance.
This measure places limitations on co-payments, enforcing that a pharmacy benefit manager or third-party payer may not charge a patient a copayment that exceeds the cost of the prescription drug.
This measure also outlines what a pharmacy benefit managers or third-party payer may not that may not prohibit a pharmacist or pharmacy from doing.
Most Recent Update: This measure has been signed by Governor Steve Bullock (D). This measure is effective January 1, 2020.
SB 265 – Revises laws regarding Medical Marijuana.
Issues: Workers’ Compensation (Medical Marijuana)
This measure generally revises laws regarding Medical Marijuana.
This measure temporarily increases the gross sales tax to 4%. This measure establishes requirements for issuance of registry ID cards and licenses. This measure establishes requirements for testing labs and establishes canopy tiers and licensing fees. This measure allows for the use of telemedicine for written certifications.
Most Recent Update: This measure has been signed by Governor Steve Bullock (D).
Except as provided, this measure is effective October 1, 2019. [Sections 30 and 31] are effective July 1, 2019. Sections 16 and 32 are effective January 1, 2020.Sections 4, 6, 7(1)(b), 9, 11, 13, 19, 25, and 29 are effective on the earlier of July 1, 2020, or the date that the department of public health and human services certifies to the Code Commissioner that the seed-to-sale tracking system is able to:(a) track a registered cardholder’s purchases of marijuana and marijuana infused products from any provider or marijuana-infused products provider, not just the provider that the cardholder has named in the cardholder’s applications for a registry identification card; (b) alert all providers and marijuana-infused products providers that a registered cardholder has reached the maximum daily or monthly purchase limit; and(c) prevent additional sales to a cardholder who has reached the daily or monthly maximum purchase limit. Sections 2; 3; 5(4)(c), (5)(d), (6), (9)(c), and (9)(d); 8(1)(i) and (7)(b); 10(1)(a)(vi), (6)(d), (7), (9)(c), and (9)(d); 12; 20; 22; 23(8) through (10); 24(8); 28(1)(f); and 33 through 39] are effective immediately.
The Montana Rule 24.29.2311 (effective July 1, 1993) allows an injured worker to choose a Managed Care Organization (MCO) from a list of certified MCOs provided by the insurer. If the injured worker does not select a MCO within 7 days, the insurer may select a MCO for the injured worker. The MCO will designate a treating physician for the injured worker appropriate to the injury. Once an injured worker has entered into a MCO and a treating physician has been selected, the injured worker may not change the MCO or the treating physician without approval from the insurer.