CA DWC Implements a Drug Formulary for Injured Workers
California’s (CA) Workers’ Compensation Medical Treatment Utilization Schedule (MTUS) drug formulary is approved, and the new regulations go into effect on January 1, 2018. The drug formulary is the state’s approach to tackling the overuse/abuse of opioids and to promote the use of frontline drugs in the treatment of injured workers.
The CA Division of Workers’ Compensation (DWC) held educational webinars on Dec 13th & 14th to educate stakeholders on the new formulary. Their presentation should be available on the DWC website soon.
The DWC recently adopted the most current version of the American College of Occupational and Environmental Medicine (ACOEM) guidelines into MTUS with the exception of the new traumatic brain injury guideline. The new drug formulary is also based on ACOEM guidelines.
The formulary list contains 275 drugs with 82 listed as exempt and 193 listed as non-exempt. If treatment is in accordance with MTUS (based on ACOEM chapters), exempt drugs can be prescribed without going through the Prospective Utilization Review process.
For the most part, non-exempt and unlisted drugs need to be authorized through Prospective Review. There is special criteria when a limited fill for certain drugs is allowed without Prospective Review. If the fill is at an initial visit within 7 days of the date of injury (Special Fill) or 4 days prior to and after surgery (Perioperative Fill) then it is allowed. There are also rules on the use of brand name drugs, physician dispensed drugs, compounded drugs, and off label use.
The drug formulary applies to all outpatient drugs dispensed on or after January 1, 2018 regardless of date of injury with one exception. In Section 9792.27.3 of the regulations it states that for ongoing drug treatment initiated prior to January 1, 2018, the treating physician is responsible for the plan of care if weaning, tapering, or transitioning to a different drug is indicated. In this case, the treating physician is required to provide supporting documentation to substantiate the medical necessity of, and to obtain authorization for, the non-exempt, unlisted, or compounded drug pursuant to the MTUS. The progress report and RFA should be submitted no later than April 1, 2018.
Shearwater Health Nurses prepare for any regulated changes in the industry and are trained on this new formulary. Our regulatory compliance department continues to monitor for updates to the formulary, so that our team has the most current standards available.