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CA Workers' Comp Alert: MTUS Drug Formulary Update

April 27, 2018 by Catherine Montgomery

California’s Division of Workers’ Compensation (DWC) ordered an update to the state’s drug formulary, effective May 15.

The update adds 20 drugs to the formulary and removes 12, bringing the total listed drugs from 275 to 283 drugs. The update also includes one change in exemption status, changes to “special fill” rules, and changes to application recommendations for several drugs.

First Update

The drug formulary took effect on January 1 of this year. Per State Assembly Bill 1124, before dispensing or prescribing a drug, providers must check the formulary list to determine if the drug  requires prior authorization.

Cost containment, as well as concerns regarding opioid abuse, sparked the push to more tightly regulate pharmaceuticals.

The MTUS formulary lists drugs in alphabetical order and designates each either:

  • Exempt: does not require prior authorization
  • Non-exempt: requires prior authorization


The formulary list notes exceptions to “non-exempt” status, referred to as “special fill.” When a drug is assigned a “special fill” exception, a provider may dispense or prescribe the drug without prior authorization, as long as the following conditions are true:

  • The drug must be generic or single-source
  • The provider must dispense the drug at the initial visit and only within 7 days of the initial injury date
  • The supply of the drug may not exceed the days indicated in the formulary list
  • Use of the drug must conform to MTUS guidelines.

The formulary also offers American College of Occupational and Environmental Medicine (ACOEM) recommendations for each drug regarding the use of the drug for various body parts and conditions.

The May 15th update to the formulary is the first update since the introduction of the formulary. A DWC Newsline announced the update which adopts two addendums to the formulary: one highlighting the changes with strikethroughs and red font, the other a clean final version of the list, effective May 15.

What’s New - Updated Formulary

Per the update order, the table below lists:

  • Drugs Added - New drugs added to the formulary list. The table indicates the exemption status of each newly added drug; only one new drug (Prednisolone Sodium Ophth) is “non-exempt,” requiring providers to obtain prior authorization before prescribing.
  • Drugs Deleted - Drugs deleted from the formulary list. Drugs not listed in the formulary require authorization. Therefore, deleted drugs require authorization effective May 15..
  • Exemption Status Changes - Changes to the exemption status of drugs on the formulary list. The update formulary changes the exemption status of one drug currently on the formulary list: Cyclopentolate HCL will be “non-exempt” and require prior authorization.
  • “Special fill” Changes - The updated formulary changes the “special fill” status of four drugs.
  • ACOEM Guidelines Changes - All drugs for which ACOEM guidelines changed.

MTUS Formulary Changes Effective 5/15/18

Drug

Drugs Added

Alcaftadine (exempt)

Azelastine Ophth (exempt)

Azithromycin Ophth (exempt)

Bepotastine Ophth (exempt)

Besifloxacin Ophth (exempt)

Cromolyn Sodium (exempt)

Desloratadine (exempt)

Emedastine Ophth (exempt)

Epinastine HCL (exempt)

Flurbiprofen Sodium (exempt)

Irrigating Eyewash (exempt)

Ketotifen Fumarate (exempt)

Lidocaine HCl Ophth (exempt)

Lodoxamide Ophth (exempt)

Loratadine (exempt)

Natamycin Ophth (exempt)

Nedocromil (exempt)

Olopatadine HCL (exempt)

Prednisolone Sodium Ophth (non-exempt)

Tranexamic Acid (exempt)

Drugs Deleted

Bacitracin Ophthalmic

Bacitracin-Polymyxin B Ophthalmic

Balanced Salt Solution

Gentamicin-Prednisolone Ace Ophthalmic

Neomycin/Bacitracin/Polymyxin B Ophthalmic

Neomycin/Polymyxin B/Gramicidin Ophthalmic

Nepafenac Ophthalmic Suspension

Polymyxin B-Trimethoprim

Rimexolone Ophthalmic

Sodium Sulfacetamide

Sulfacetamide Sodium/Prednisolone

Tobramycin/Dexamethasone

Exemption Status Changes

Cyclopentolate HCL (non-exempt)

Special Fill Changes

Betamethasone (4 days)

Dexamethasone Sodium Phosphate Ophthalmic (4 days)

Fluorometholone (4 days)

Loteprednol Etabonate Ophthalmic (4 days)

ACOEM Guidelines Changes

Acetaminophen

Celecoxib

Choline Magnesium Trisalicylate

Chondroitin Sulfate

Ciprofloxacin HCL Ophthalmic

Clindamycin HCL

Cyclopentolate HCL

Diclofenac Potassium

Diclofenac Sodium/Misoprostol

Diflunisal

Doxycycline

Etodolac

Fenoprofen Calcium

Fluorometholone

Flurbiprofen

Gatifloxacin

Homatropine HBr Ophthalmic

Ibuprofen

Imipramine HCL

Indomethacin

Ketoprofen

Levofloxacin Ophthalmic Solution

Loteprednol Etabonate Ophthalmic

Meclofenamate Sodium

Mefenamic Acid

Meloxicam

Moxifloxacin HCL Ophthalmic

Nabumetone

Ofloxacin Ophthalmic Solution

Oxaprozin

Prednisolone Acetate

Salsalate

Sulindac

Tobramycin Ophthalmic

Tolmetin Sodium

Tropicamide Ophthalmic

An Easier Formulary

If poring over 22 pages of 8-point font to check the status of a given drug isn’t your idea of efficiency, DaisyBill offers an alternative to the DWC drug formulary PDF.

Blatant pitch alert: Our Work Comp Wizard now includes the Drug Formulary Tool. Providers can search and filter the formulary list in 3 easy steps.

1. You simply click ‘Drug Formulary

2. Apply the filters of your choice. You can choose to see only “exempt” drugs, for example, or drugs listed by class or patient condition.

3. Enter a search term, such as the name of a drug, class, or condition.

Just like that, you have the information you need — without the time wasted by manually scouring through the DWC Formulary PDF.

For a free trial of the formulary tool, sign up below.

TRY THE FORMULARY TOOL

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