Closed Formulary for Workers’ Compensation Patient
The Texas Division of Workers’ Compensation (DWC) has a closed drug formulary (PDF) for treating injuries that occur on or after Sept. 1, 2011.
DWC regulations (PDF) define the formulary as all Federal Drug Administration-approved drugs, with the exception of the following:
- Drugs with “N” status identified in the current and subsequently updated editions of the Official Disability Guideline (ODG) Treatment in Workers’ Comp — Appendix A, ODG Workers’ Compensation Drug Formulary;
- Any compounded drugs that contains a drug identified with an “N” status in ODG; and
- Drugs considered investigational or experimental.
For drugs not included in the formulary, physicians must get preauthorization by the insurance carrier prior to prescribing them to an injured patient being treated under the Texas workers’ compensation system.
Pre-Sept. 1, 2011, Injuries
For patients who suffered workplace injuries prior to Sept. 1, 2011, the formulary remains open until Sept. 1, 2013.
However, physicians who treat these “legacy patients” must take action during the transition to the closed formulary if they are prescribing medications that have been identified with an “N” status by ODG. At any time between Sept. 1, 2011, and Sept. 1, 2013, the physician should include a statement of medical necessity with the prescription.
Health insurance carriers also have a duty for these legacy patients during the transition period. Prior to March 1, 2013, insurance carriers must notify the physician, the injured worker, and the pharmacy in writing when they receive claims on legacy patients where an excluded drug has been prescribed after Sept. 1, 2012. The written notice will give information on how physicians can contact the carrier directly to discuss ongoing pharmacological management of the injured worker’s claim.
TMA will keep you posted of updates. Also look for new continuing medical education opportunities. For more information, contact TMA Knowledge Center at (800) 880-7955 or knowledge.texmed.org.