Board Continues Drug Formulary Rollout
As we reported in our last issue, the Board’s Prescription Drug Formulary is live, and the Board is setting up the Prior Authorization system for the Drug Formulary. Stakeholders in the workers’ compensation system should be aware of the need to set up contact information with the Board, the 12/5/19 transition to use of the Drug Formulary for new prescriptions, the requirement to notify providers and claimants about the transition to the Drug Formulary, and the Formulary’s treatment of narcotic/opioid medications.
Board Requests Contact Information from Payers
The Board has asked payers (insurance carriers, self-insured employers, and third-party administrators) to identify contacts for their organization as well as provide an electronic mailbox for each. To do this, each organization must go to the Board’s Drug Formulary Administration webpage and enter their Level 1, Level 2, and Order of the Chair contacts for their organization. Please note that the requirement for Order of the Chair contacts is not included in the Drug Formulary or the regulation that incorporates it, but it is noted on the Board’s Drug Formulary Administration webpage.
Recall that Level 1 review is an internal review conducted by the payer. The Board requests that the Level 1 review contact information be an email address of the insurance carrier, TPA, or Pharmacy Benefit Manager (PBM), if designated. Level 2 review is the insurance carrier’s physician as defined in the Drug Formulary regulations. Thus, the contact information here should be that physician’s email address. Finally, the “Order of the Chair” contact information should include an email address for both the claim administrator and the insurance carrier.
New Prescriptions After 12/5/19 Must be for Drug Formulary Medications
Payers should be aware that as of 12/5/19, any new prescription from a provider must be for a Drug Formulary medication. If the provider wants to prescribe a non-formulary drug, that provider must obtain prior authorization from the payer before writing the prescription. A “new prescription” is a prescription for a drug that the claimant is not currently taking, and this includes different drug strengths or frequencies of drugs that the claimant is taking prior to 12/5/19
Refills and Renewals of Drugs – Payer Notification Requirements and the 6/5/20 Deadline
Payers are required to notify medical providers and claimants no later than 12/5/19 whether any drugs a claimant is currently being prescribed are not on the Drug Formulary. The Board has provided form letters for notification to claimants and providers showing the format of the notification that it requires.
On or after 6/5/20, all refills or renewals of prescriptions must use a Drug Formulary medication unless the payer has given prior authorization to the provider before the date of the refill or renewal. A refill is defined as any subsequent fill of a prescription when the number of refills is explicitly included in the original prescription. A renewal is defined as a prescription that the claimant has been taking but for which there are no available refills.
Narcotics and Opioids
Recall that the Drug Formulary does not include narcotic or opioid medications after the first 30 days from an injury (with the exception of the perioperative period as defined in the formulary). Moreover, on or after 12/5/19, the provider may only prescribe up to a single seven-day supply of a narcotic or opioid in the first 30 days following an injury. The Board also expects providers and claimants plan for a transition from narcotics/opioids to a Drug Formulary medication before 6/5/20. Should such a transition not be medically appropriate, the provider should obtain prior authorization of a refill or renewal of the narcotic/opioid before 6/5/20.
For a refresher on the changes coming with the Drug Formulary, please review our prior article and the Board’s Subject Number 046-1198. For any questions about the Drug Formulary, please contact our partner, Renee Heitger.