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PA Supreme Court Issues Ruling with Possible Impact on OTC Medications
April 4, 2025 · Public Policy & Regulatory Affairs Team
A recent ruling by the Pennsylvania Supreme Court changes how some over the counter (OTC) medications are prescribed and provided to injured workers. In the particular case of Schmidt v Schmidt, Kirifides and Passias, PC and the Workers’ Compensation Appeal Board (found here),, the Court ruled that a broader interpretation of approved “medicines and supplies” (as found in Section 306(f.1)(1)(i) of the Workers’ Compensation Act) should be applied for certain treatments.
In this case, after receiving a prescription for CBD oil, the injured person subsequently purchased the “over the counter” product at a local health food store. Consequently, the workers’ comp carrier declined to reimburse the injured person for the cost of the CBD oil. A resulting fee dispute ruled in favor for reimbursement to the injured person. After the Pennsylvania Commonwealth Court affirmed the initial ruling, and an appeal, the case came before the Pennsylvania Supreme Court.
After reviewing case facts and decisions of the lower court, the Supreme Court concluded that trying to fit a physician recommended item (such as CBD oil) into the “medicine or supply” category was neither necessary or relevant and that the phrase should be considered as a single term meant to include anything a treating physician “determines is a component of a treatment plan for a work-related injury.” The Court also ruled on the question of whether or not a particular item is FDA approved as “only relevant to determination of reasonableness and necessity of the product in conjunction with a utilization review petition.”
Potential Impact
On its face, the case could now expand the number and type of non-prescription items, including OTC medications, non-FDA approved analgesics, and CBD oils for which insurance carriers must pay providers or reimburse the injured person’s out-of-pocket cost. Additionally, physicians could now have a green light to prescribe anything the claimant wants or believes will help treat their work-related injury or condition. Finally, it is important to point out that reimbursement for such items shall be at retail cost.
Additional Optum resources: For more information on these policy developments and others we have been tracking this year, be sure to visit our Legislative and Regulatory Tracker. Bills or regulations can be filtered by insurance line, topic, status and jurisdiction. If you have questions on these or any other public policy developments, please contact our team at OptumWC.PolicyMatters@optum.com. |
