Texas Department of Insurance Division of Workers’ Compensation

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 Informal Working Draft Rules • § 134.500 Definitions • § 134.506 Outpatient Drug Formulary (Proposed to be Repealed) • § 134.507 Outpatient Drug Formulary - Closed • § 134.508 Use of the Closed Drug Formulary for Claims Not Subject to Certified Networks • § 134.509 Use of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 URA’s • 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 Division’s formulary • May not develop alternate formularies • Must reimburse according to the Division’s fee guidelines

7. 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

8. 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

9. ODG – Appendix A (example)

10. 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

11. 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

12. Next Steps • Additional research • Informal working draft rules • Proposal • Public Comment • Adoption • Implementation