The Florida Division of Workers’ Compensation (DWC) has adopted an updated Florida Workers’ Compensation Health Care Provider Reimbursement Manual that will take effect January 1, 2025. Prompted by changes in the law related to medical provider reimbursement, the newly adopted manual also includes updates for pharmacy services.
Authorization for convenience kits
While many of the adopted changes to the manual are more impactful to other medical services, the DWC did include one substantive addition specific to pharmaceutical reimbursement and authorization. “Convenience kits” will now be identified as a “specialty service” under section 440.13(3)(i) of the Florida Statutes. Now following the same authorization process as compounded medications, these convenience kits will not be reimbursable unless they have been expressly authorized by the carrier (unless the carrier has failed to respond within 10 days to a written request for authorization, or unless emergency care is required).
Though not defined in the manual, “convenience kits” is a term that refers to two or more different products packaged together for the intended convenience of the user. Medication convenience kits commonly seen in workers’ compensation claims are typically used for pain and inflammation. However, these kits often become unnecessary cost drivers given the individual components are available separately at significantly lower prices.
Amended out-of-state provider reimbursement
The manual’s general language outlining provider reimbursement to out-of-state health care providers when the claim is a Florida workers’ compensation claim was also amended. As updated, reimbursement to out-of-state providers should follow an agreed upon contract price, where applicable, or the applicable Florida fee schedule rate. Prior to this change, the required reimbursement for out-of-state providers was the greater of the applicable Florida fee schedule rate or the provider state’s fee schedule rate.
Moving forward
The new convenience kit authorization requirement will add another hurdle for providers when seeking to prescribe and/or dispense these costlier medication products, which may lead to lower overall costs to insurers and employers in the state. The amended reimbursement for out-of-state providers should also reduce costs to payers in some instances where the provider’s state fee schedule happens to be higher than the Florida fee schedule.
The MyMatrixx Regulatory Affairs team attended the hearing for these changes when they were proposed and provided written comments in support of the new authorization requirement for convenience kits to help curb unnecessary costs in the system. The Florida DWC previously stated it intends to address other potential substantive changes to the manual in 2025, and we look forward to participating in those discussions. We encourage our clients to stay involved in that process as well.
Questions on this topic for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments like this in workers’ compensation impacting pharmacy in states across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.