When state legislators proposed a workers’ comp drug formulary back in 2015, they knew it would take some time to work out all the kinks. But legislators may not have foreseen this much time. The implementation of the formulary has already been delayed, from July 1, 2017 to January 1, 2018. Now, the latest draft of the formulary rules are available for public comment – and voices across the workers’ comp system are chiming in with feedback.
The purpose of the drug formulary is to establish a list of medications that are considered appropriate for use in the treatment of California’s injured workers. The formulary would assign drugs to one of two separate lists – “exempt” drugs do not require utilization review and “non-exempt” drugs that would still be subject to the lengthy utilization review process.
We applaud the state for its noble goal, and we’re delighted that California is using its formulary as an opportunity to lead the charge in the national battle against opioid addiction. No opioids appear on the proposed list of “exempt” drugs, meaning that treating physicians prescribing opioids must receive express approval through UR.
Like any monumental undertaking, the implementation of the drug formulary is rife with complexity. For example, it’s one thing to commit to reducing opioid dependency going forward. But what of severely injured workers who already have opioid prescriptions? Knowing how to wean these workers off of their prescribed drugs gently is tricky business.
Consider this scenario: Say an injured worker with a chronic condition has taken the same drug for five years. For the sake of this hypothetical, we’ll assume that that drug is on the “non-exempt” list, and subject to utilization review. Under the new proposed drug formulary rules, before January 1, 2018, the worker’s treating physician must submit a progress report to utilization review that outlines a plan to wean the worker off of their non-exempt medication and to transition the worker to an exempt drug. Or the progress report should explain the medical necessity of the continued use of the non-exempt drug.
But what if the primary treating physician and the utilization review company disagree on the medical necessity of the non-exempt drug? UR could deny the request and terminate the prescription, leaving the physician scrambling to implement a brand new treatment plan and cutting the worker off of their long-standing medication. It’s a thorny hypothetical, and one that may require further thought before the formulary’s implementation on the first of next year.
In the meantime, we encourage you to make your voice heard. Read the proposed formulary rules on the DIR website and send any written feedback by 5:00 PM on Wednesday, August 2 to the address below:
Maureen Gray, Regulations Coordinator
Department of Industrial Relations
Division of Workers' Compensation
1515 Clay Street, 18th floor
Oakland, CA 94612
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