The drugs, listed as "N" drugs in Appendix A of the Official Disability Guidelines -- Treatment in Workers' Comp, require preauthorization or they will not be reimbursed. The state adopted the legislation to curb the use of the approximately 150 drugs that include addictive painkillers and muscle relaxers.
"The adopted closed formulary rules included a bifurcated application timeframe for initial and existing claims," said the Texas Department of Insurance in a memo to practitioners. "Please note that as of September 1, 2013, all outpatient certified workers' compensation health care network and non-network injured employee claims are subject to the closed formulary."
The memo said preauthorization is required for all prescriptions excluded from the closed formulary unless there is a documented agreement between the insurer and the prescribing doctor for a legacy claim. Prescriptions covered under the formulary are subject to retrospective review of medical necessity by a certified or registered utilization review agent. However, if an agreement was made between an insurance carrier and a prescribing doctor for a legacy claim, then any health care provided as a result of the agreement is not subject to retrospective review of medical necessity.
Last year the TDI issued a report on the impact of the closed formulary. It said that since the implementation of the law, the following changes had occurred:
- The number of injured employees receiving N-drugs fell by 60 percent.
- N-drug costs fell by 81 percent, and N-drug costs as a percentage of all drug costs decreased by 75 percent.
- The number of injured employees receiving other drugs fell by 5 percent.
- The share of N-drug claims among all claims fell by 56 percent.
- The total number of prescriptions for N-drugs fell by 68 percent.
- The number of prescriptions for the 10 most-prescribed N-drugs decreased by 71 percent.
- The total number of prescriptions for other drugs fell by 7 percent.
By Nancy Grover
Read more at the WorkersComp Forum homepage.
September 30, 2013
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