Texas Department of Insurance Division of Workers

1
Texas Department of InsuranceDivision of
Workers Compensation

• Pharmacy Closed Formulary
• Stakeholder Meeting
• March 5, 2009

2
Agenda

• Introductions
• Overview of the Informal Working Draft Rules
• Stakeholder discussion of issue specific topics
  based on informal comments
• Further rules development and stakeholder input
  consideration beyond the Informal Working Draft
  Rules
• Next Steps

3
Informal Working Draft Rules

• 134.500 Definitions
• 134.506 Outpatient Drug Formulary (Proposed to
  be Repealed)
• 134.507 Outpatient Drug Formulary - Closed
• 134.508 Use of the Closed Drug Formulary for
  Claims Not Subject to Certified Networks
• 134.509 Use of the Closed Drug Formulary for
  Claims Subject to Certified Networks

4
Clarifications

• Preauthorization
• TDI URA rules
• Additional TDI-DWC rules
• Only by Certified/Registered URAs
• Prospectively determines medical necessity
• Does not address compensability or relatedness
• Voluntary Certification
• Allowed by 413.014 and 134.600
• Only for items not requiring preauthorization
• No retrospective review of medical necessity or
  compensability
• Must be documented

5
Clarifications

• The informal working draft rules do not
  anticipate a preferred drug list
• Carriers and their agents may not restrict
  prescriptions through the use of alternative
  formularies
• Initial Pharmaceutical Coverage
• TLC 413.0141 - Initial Pharmaceutical Coverage
• TAC 134.501 - Initial Pharmaceutical Coverage
• Carriers may recover from SIF for non compensable
  injuries
• Implies carrier retrospective denial on not
  medically necessary prescriptions
• Generics are required through
• TLC 408.028 and
• TAC 134.502

6
Clarifications

• Carriers contracting with networks are required
  to utilize the Divisions formulary
• May not develop alternate formularies
• Must reimburse according to the Divisions fee
  guidelines

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Open Formulary (currently in place)
Open Formulary - Includes all FDA approved drugs
Preauth Required
Outside, in excess of, not addressed in ODG
treatment
W/I ODG treatment
SOMN/Evidence
Exceptions Emergency 134.501
Retrospective Review
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IWDR Closed Formulary (informal rule)
Drugs w/ status N Requires appeals process
Closed Formulary
Outside, in excess of, not addressed in ODG
treatment
W/I ODG treatment
SOMN/Evidence
Preauth Required
Exceptions Emergency w/Retrospective
Review 134.501
Retrospective Review
Contraindication/Other
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ODG Appendix A (example)
Drug Class Generic Name Brand Name GE Status Cost
Opioids Fentanyl lollipop Actiq Y N 1,048.00
Nonprescription analgesics Ibuprofen Advil Y-OTC Y 3.56
NSAIDs Ibuprofen Advil Y-OTC Y 3.56
Nonprescription analgesics Naproxen Aleve Y-OTC Y 5.16
NSAIDs Naproxen Aleve Y-OTC Y 5.16
Sedative-hypnotics Zolpidem Ambien Y (not CR) Y 30.69
Opioids Morphine Avinza N Y  
Nonprescription analgesics Aspirin Bayer Y-OTC Y 1.92
Topical analgesics Salicylate topicals Ben-Gay Y-OTC Y N/A
Botulinum toxin Botulinum toxin Botox N N  
Central adrenergic agonists Clonidine Catapres Y (not patches) N 1.95
Herbal medicines Uncaria Tomentosa Cat's Claw Y-OTC Y N/A
NSAIDs (non-steroidal anti-inflammatory drugs) Celecoxib Celebrex N Y 93.42
Cannabinoids Nabilone Cesamet N N  
Topical analgesics Capsaicin, topical Chili pepper Y N N/A
Herbal medicines Chondroitin sulfate Chondroitin Y-OTC Y N/A
Herbal medicines Cod liver oil Cod liver oil Y-OTC Y N/A
Opioids Codeine Codeine Y Y  
Gout medications Colchicine Colchicine Y N  
Antidepressants Duloxetine Cymbalta N Y 113.70
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Commenter topics

• Applicability
• Prescribed or dispensed date
• Refills
• Implementation period
• Licensed pharmacy limitation
• Acute injury vs. chronic injury formularies
• Compounding
• Statement of Medical Necessity
• Preauthorization

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Long term medical management

• Application of formulary to legacy claims
• Long term narcotic/opioid use
• Treatment planning
• Requirements of the Texas Medical Board
• Coordination with DWC rules

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Next Steps

• Additional research
• Informal working draft rules
• Proposal
• Public Comment
• Adoption
• Implementation