Pennsylvania
Pennsylvania Court Rejects Red Book Pricing in Workers' Compensation
In the case of Federated Insurance Co. v. Summit Pharmacy, the Pennsylvania Commonwealth Court challenged the state’s method of calculating pharmaceutical costs in workers’ compensation cases.
In the case of Federated Insurance Co. v. Summit Pharmacy, the Pennsylvania Commonwealth Court challenged the state’s method of calculating pharmaceutical costs in workers’ compensation cases.
The court objected to the use of Red Book values, which are similar to the manufacturer’s suggested retail price of a car, to determine the average wholesale price (AWP) of drugs.
Federated Insurance Co. sought a review of an order from the Pennsylvania Bureau of Workers’ Compensation that required the insurer to pay Summit Pharmacy approximately $72,500 to reimburse the cost of generic drugs provided to a claimant for her work-related injuries.
The hearing officer used the Red Book values to calculate this reimbursement amount, a practice adopted by the Bureau for resolving disputes over pharmaceutical costs.
The insurer argued that the Bureau’s use of Red Book values was inconsistent with Pennsylvania’s Workers’ Compensation Act, which limits the reimbursement of pharmaceuticals to 110% of the AWP. The insurer also contended that the Bureau’s ongoing use of the Red Book represented an improper delegation of legislative authority to a private entity.
Summit Pharmacy, on the other hand, argued that AWP is a term of art used within the pharmaceutical industry, which regards the Red Book as an accepted source of AWP. According to Pennsylvania precedent, AWP is intended to be an objective estimate of drug acquisition costs derived on a national basis.
The court sided with the insurer, ruling that Red Book values did not reflect AWP as required by the Workers’ Compensation Act. The court directed the Bureau to identify and publish a different, nationally recognized schedule to determine AWP, reasoning that AWP should be an industry average price, not one charged by a single manufacturer. It noted that the Red Book’s publisher followed a policy under which AWP was reported by manufacturers, calculated based on a markup specified by the manufacturer and suggested wholesale price was reported by the manufacturer.
Scorecard: The court ruled that the use of Red Book values to calculate prices for pharmaceuticals in workers’ compensation cases is inconsistent with the state’s Workers’ Compensation Act. The Bureau has been directed to identify and publish a different, nationally recognized schedule for determining AWP.
Takeaway: This ruling underscores the importance of insurers understanding and challenging the methodologies used to calculate reimbursements in workers’ compensation cases. It may prompt a review of similar practices in other jurisdictions, potentially leading to more accurate and fair reimbursement rates. &
A Pennsylvania court ruling is reshaping abortion access in the state, striking down a decades-old ban on using Medicaid to pay for abortions and declaring that the Pennsylvania Constitution guarantees a right to abortion.
The decision came Monday from the state’s Commonwealth Court. In a 4-3 vote, judges ruled in favor of abortion rights in Pennsylvania and invalidated the state’s restriction on Medicaid-funded abortions.
Local abortion-rights advocates praised the ruling as a major step toward protecting access for low-income residents. Adrienne Daily, co-founder of Johnstown for Choice, said, “Everybody should have the right to that. If you restrict the coverage, you’re obviously discriminating against those that have lower income.”
Opponents of abortion rights called the decision a dramatic expansion of the court’s power and warned it will force taxpayers to pay for procedures they oppose. Michael Geer, president of the Pennsylvania Family Institute, said, “Taxpayers now in Pennsylvania will have no choice under this court ruling to fund abortions. And there are many, many millions of Pennsylvanians who think abortion is wrong. It’s the taking of an innocent human life and to force taxpayers who conscientiously object to abortion to then fund it is just plain wrong.”
Abortion-rights advocates pushed back, arguing abortion access is healthcare and a personal decision. Daily said, “This is a family issue. This is a personal issue. This is a bodily autonomy issue.”
Pro-life leaders also warned the ruling could have broader implications for other abortion-related laws. Geer said, “It is sweeping and there’s no question it’s judicial overreach.” He added, “If this ruling stands, it will invite attacks on every remaining pro-life safeguard that has been put into law by lawmakers at the behest to the people of Pennsylvania over decades.”
The case could still be appealed to the Pennsylvania Supreme Court. That decision lies with Republican Attorney General Dave Sunday. His office has not provided a response, but the Associated Press reported a spokesperson said the office is reviewing the decision and did not say whether it will appeal.
Johnstown, Pa. (WJAC) — The Rock and Roll Hall of Fame just released this year’s list of inductees, and a new clothing store just opened in the Johnstown Galleria.
What do these two things have in common?
If you grew up listening to 90’s hip-hop, then you’re probably familiar with the Wu-Tang Clan.
Wu-Tang Clan member opens clothing store in Pennsylvania (WJAC)
They said, “We’re in the building right now, we’re out in Johnstown making it happen, fashion and rapping, and Wu-Tang, you already know Wu-Tang is the witty, unpredictable talent and natural game. So, it’s all grassroots with us, man. We do everything from scratch.”
They’re being inducted into the Rock and Roll Hall of Fame this year, and Darryl Hill, aka Cappadonna, and manager Al “Heck” Felder are opening the Pillage, a clothing store in the Johnstown Galleria, selling apparel with a purpose.
Cappadonna said, “‘Cappadonna,’ that stands for ‘Consider All Poor People Acceptable, Don’t Oppress Nor Neglect Anyone,’ and we stand on that.”
They were introduced to mall owner Leo Karruli through Mustafa Curry, a childhood friend from New York, who owns a store on Main Street in Johnstown.
Heck said, “BK Styles, I’ve got to give a shout out to my boy, Mustafa. They’ve got some apparel down there, too. We’re all over. We’re spreading the word and we’re spreading the love.”
Wu-Tang Clan member opens clothing store in Pennsylvania (WJAC)
Their other clothing line, Angry Elephant, promotes being good stewards of the Earth, with a portion of the proceeds protecting the animals from poachers.
They said they believe in always putting God and family first.
Cappadonna said, “When you recognize the God in us, then you can see the God in you.”
They said they want kids to know that violence is not the answer, and it doesn’t cost anything to be kind.
Cappadonna said, “We just want to say that it’s nice to be important, but it’s even more important to be nice.”
A mother and her six children died when their Central Pennsylvania home exploded and caught on fire Sunday morning, state police said.
The explosion and fire happened at around 8:30 a.m. at a home on Long Run Road in Lamar Township, Clinton County, which is roughly 35 miles from State College. Crews arrived on the scene and found the home fully engulfed in flames, with the mother and her six children trapped.
State police identified the 34-year-old woman who died in the fire as Sarah B. Stolzfus. Her 11-year-old son, 10-year-old son, 8-year-old daughter, 6-year-old daughter, 5-year-old son and 3-year-old son also died in the blaze, according to state police.
A propane leak inside the house might’ve caused the explosion and fire, state police said. Propane tanks outside the home did not explode or contribute to the fire, according to state police.
The explosion and fire are under investigation by state police.
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