October 2011

Claims Corner

DWC adopts closed formulary for prescription medications

By Laura Joy

The long-term use of narcotics and opioids by injured workers has caused concerns about the potential harmful side effects, including addiction. For several years, regulators and the medical and insurance community have increasingly focused on the use of pharmaceuticals in workers’ compensation.

In 2005, House Bill 7 directed the Texas Department of Insurance, Division of Workers’ Compensation (DWC) to propose rules for a closed formulary. HB 7 defined evidence-based medicine into the Texas Labor Code. DWC formally adopted the Official Disability Guidelines (ODG) as the accepted evidence-based guideline for the treatment of Texas workers’ compensation patients. These guidelines are supported with published medical studies supporting the medical treatment provided in the treatment of certain conditions or injuries. Included with the ODG is a formulary listing of prescription medications.

Effective Sept. 1, the Texas workers’ compensation statute and rules require the use of a closed formulary for workers’ compensation patients. The accepted closed formulary is contained in the ODG. In the closed formulary some drugs are classified as status “N,” which are excluded from the closed formulary and require preauthorization.

These changes only affect injuries occurring on or after Sept. 1. Claims occurring prior to that date, referred to as legacy claims, are not affected and preauthorization for medications will not be required at this time. Legacy claims will be transitioned to the required preauthorization criteria not later than Sept. 1, 2013, and after discussion with the treating doctors. Injured employees with claims prior to Sept. 1 of this year should see no differences in the delivery of pharmacy benefits. Injured employees who are prescribed N-class drugs should be aware that their doctor and the dispensing pharmacy will be communicating with our preauthorization agent, ScriptNet, regarding the medical necessity of the prescribed drugs. This process must not take longer than three days and often happens in much shorter timeframes. ScriptNet will make every effort to reduce the turnaround time, and injured employee should be able to fill their prescriptions promptly.

Above is a timeline showing the formulary distinctions between the older claims and the new requirements. SORM encourages all injured employees to actively discuss treatment and medications with their treating physician.

These changes affect the entire workers’ compensation industry, not just SORM claims. SORM is working with ScriptNet to make this process as seamless as possible. TDI is attempting to educate many doctors and pharmacies about these new rules. As problems come up, injured employees of your agency may contact you regarding delays in receiving, or the inability to receive, their medications. SORM staff is available at (877) 445-0006 to answer any questions you have about the formulary or the preauthorization process.

Laura Joy is the deputy director of the Claims Operations division.