Part I.
General Provisions
Pursuant to Ark. Code Ann.
11-9-517
(Repl. 1996) and Commission Rule
099.02 (Effective March 1, 1982)
the following rule is hereby established in order to implement a workers'
compensation Drug Formulary. This Rule is adopted for all prescriptions for
workers' compensation claims with a date of injury on or after July 1,
2018, and applies to all FDA approved drugs that are prescribed and
dispensed for outpatient use.
A.
Scope.
1. This rule does all the
following:
(a) Adopts by reference as part of
this rule the Public Employee Claims Division (PECD) Workers' Compensation Drug
Formulary, which is maintained and updated by UAMS College of Pharmacy Evidence
Based Prescription Program and any amendments to that formulary. The formulary
will be reviewed and updated as needed.
(b) Establishes that all initial
prescriptions for Opioids shall be limited to a 5-day supply and shall not
exceed 50 MED per day without prior authorization. All subsequent Opioid
prescriptions shall be limited to a 90-day maximum supply and shall not exceed
a 50 MED dosage limitation per day without prior authorization. With prior
authorization, a subsequent prescription may be prescribed in excess of 50 MED
but shall not exceed 90 MED.
(c)
Establishes the effective date for implementation of Rule
099.41.
(d) Establishes procedures by which all
payors shall have on staff a Pharmacist and Physician or Medical Director or
shall contract with a PBM, who has a Pharmacist and a Physician or Medical
Director on staff or has contracted with a Pharmacist and a Physician or
Medical Director.
(e) Establishes a
procedure for pharmacists filling workers' compensation
prescriptions.
(f) Provides for the
certification of all payors, determined to be in compliance with the criteria
and standards established by this rule. (See Part
II. A for certification
requirements.)
(g) Provides for the
implementation of Medical Cost Containment Division (MCCD) review and decision
making responsibility. The rule and definitions are not intended to supersede
or modify the workers' compensation laws, the administrative rules of the
Commission, or court decisions interpreting the laws or the Commission's
administrative rules.
(h) Provides
for the right to appeal from the MCCD to an Administrative Law Judge.
(i) Provides requirements in order for payors
to be held responsible for payment of FDA approved Opioid
medications.
B.
Definitions.
As used in this rule:
1.
"Administrator" means the Administrator of the Medical Cost Containment
Department of the Arkansas Workers' Compensation Commission or his/her
designee.
2. "Day" means calendar
day.
3. "Dispute" means a
disagreement between a payor, pharmacists, provider, or claimant, regarding
this rule.
4. "Filling Pharmacist"
is a pharmacist filling a prescription for medication.
5. "Initial Prescription" means the
beginning, starting, commencing, or first written order for a medication.
Changes in dosage, addition of or removal of previously prescribed medications
either individually or in combination are not considered an initial
prescription.
6. "Medical Director"
is a physician that is on staff or is contracted with either a PBM or the payor
of the worker's compensation claim.
7. "Outpatient service" means a service
provided by the following but not limited to, types of facilities: physicians'
offices and clinics, hospital emergency rooms, hospital outpatient facilities,
community health centers, outpatient psychiatric hospitals, outpatient
psychiatric units, and free-standing surgical outpatient facilities.
8. "Payor" is a self-insured entity, third
party administrator or insurance carrier which pays workers' compensation
benefits.
9. "Reviewing Pharmacist"
is an individual with a Doctorate in pharmacy or a Bachelor's degree in
pharmacy contracted with or on staff with a Payor or Pharmacy Benefit
Manager.
10. "Pharmacy Benefit
Manager" (PBM) is a third-party administrator (TPA) of prescription drug
programs.
11. "Provider" means a
facility, health care organization, or practitioner (as defined by Commission
Rule 099.30 ).
12. "MED" means Morphine Equivalent Dose Per
Day.
Part II.
Process for Requiring all Payors to contract with a Pharmacist and
Physician or Medical Director or PBM who has contracted with a Pharmacist and
Physician or Medical Director.
All payors shall have on staff or shall contract with a
Pharmacist and Physician or Medical Director or PBM who has contracted with a
Pharmacist and Physician or Medical Director or has a Pharmacist and Physician
or Medical Director on staff. Certification requires the Payor to furnish the
current name, license number, and address of their Pharmacist, PBM, and
Physician or Medical Director to the Medical Cost Containment Division of the
Arkansas Workers' Compensation Commission and update this information when
changes occur.
Part III.
Opioid Medications
A. For
workers' compensation injuries or illnesses with an incident date on or after
July 1, 2018, payors will not be held financially responsible for payment for
FDA approved Opioid medications in excess of 50 MED per day or in excess of 90
days without prior authorization. With prior authorization a prescription may
be prescribed in excess of 50 MED but shall not exceed 90 MED. The Arkansas
Workers' Compensation Commission will adopt criteria for prior authorization
for prescriptions in excess of 50 MED but not exceeding 90 MED and criteria for
recertification every 90 days.
B.
Prior to prescribing Opioid medications or Benzodiazepine, prescribers shall
check the Prescription Drug Monitoring Program (PDMP) database in accordance
with A.C.A. §
20-7-604.
C. A Payor shall not be required to pay for
more than five (5) days of medication for the first prescription of an Opioid
medication without prior authorization. A Payor shall not be required to pay
for continuing an Opioid medication beyond the first five (5) day prescription
unless all of the following requirements are met:
1. The medication is prescribed by an
authorized treating prescriber; and
2. The medication is reasonable, necessary
and related to the workers' compensation injury or illness; and
3. The provider prescribing the medication
examines the injured employee in a follow-up visit and documents to the Payor
that the medication taken so far is proving to be effective in controlling pain
associated with the employee's work-related injury or illness; and
4. The provider prescribing the medication
documents to the Payor that continuing the Opioid medication therapy is
medically necessary.
D. A
Payor shall not be required to pay for continuing an Opioid medication beyond
90 days without written certification to the Payor of medical necessity which
shall include the following:
1. Follow-up
visits with prescriber have been conducted;
2. Documentation by prescriber of improved
function under the medication;
3. A
plan for periodic urinary drug screening;
4. A detailed plan for future weaning off the
Opioid medication;
5. Documentation
within patient's record showing conservative care rendered to the worker that
focused on increased function and return to work; and
6. A statement on what prior or alternative
conservative measures were ineffective or contraindicated (including non-opioid
pain medications).
Part
IV.
Process for Filling Workers' Compensation
Prescriptions
A. Pharmacists filling a
workers' compensation prescription must verify that the prescribed drug(s) are
listed on the approved drug formulary.
B. If the prescribed drug(s) is not on the
approved drug formulary, the pharmacist must contact the Payor for approval of
the prescribed drug(s) and must consult with the Prescriber before switching
the medication to a formulary medication(s).
C. The filling pharmacist must abide by the
rule requirements for prescribed Opioids for the Payor to be required to pay
for the medication(s). ( 50 MED per day for five (5) days and a 90 day duration
without prior authorization)
D.
Compounded medications require pre-authorization from the Payor and medical
certification of the patient's inability to tolerate treatment by other
non-compounded medications.
Part
V.
Process for Resolving Disputes Between Provider and
Reviewing Pharmacist or PBM
When the Payor denies the medication and the injured employee,
filling pharmacist, or prescriber insists on the medication that has been
denied, a reconsideration may be made to the reviewing pharmacist on staff or
contracted with the Payor or the Payor's PBM by submitting a Reconsideration
Form. The Payor should promptly send a Reconsideration Form to the prescriber
to complete and submit together with any supporting documentation to the
reviewing Pharmacist. The reviewing Pharmacist shall have three (3) business
days to consult with the Prescriber or Medical Director, if necessary, and to
respond to the reconsideration request. If the reviewing Pharmacist does not
respond within three (3) business days, the filling pharmacist may fill the
prescription. If the reviewing Pharmacist denies the reconsideration request,
an appeal may be made within 10 business days to the Medical Cost Containment
Division of the Arkansas Workers' Compensation Commission.
Part VI.
Hearings
A.
Administrative Review
Procedure
An appeal may be made to the Administrator of the Medical Cost
Containment Division by mail, fax, or email.
Administrator of the Medical Cost Containment Division
P.O. Box 950
Little Rock, AR 72203-0950
501-682-1790 fax
501-682-2747 fax
Phannah@awcc.state.ar.us
1. Appeals will be reviewed by the Medical
Cost Containment Division and a determination will be issued within three (3)
business days of receipt of the appeal and supporting documentation.
2. An appeal may be rejected if it does not
contain the following information:
(a) Injured
employee name;
(b) Date of birth of
injured employee;
(c) Social
Security Number of injured employee;
(d) Arkansas Workers' Compensation File
Number;
(e) Date of
Injury;
(f) Prescriber's
name;
(g) Prescriber's DEA
number;
(h) Name of drug and
dosage;
(i) Requestor's name
(pharmacy or prescriber);
(j)
Requestor's contact information;
(k) A statement that the approval request for
a prescribed drug(s) has been denied by the insurance carrier, accompanied by
the denial letter if available;
(l)
A statement that the prior approval denial poses an unreasonable risk of a
medical emergency and justification from a medical perspective such as
withdrawal potential or other significant side effects or
complications.
(m) A statement that
the potential medical emergency has been documented in the prior approval
process.
(n) A statement that the
insurance carrier has been notified that a request for an expedited
determination is being submitted to the Arkansas Workers' Compensation
Commission; and
(o) The signature
of the requestor and the following certification by the requestor for
paragraphs (g) to (o) of the above subsection, "I hereby certify under penalty
of law that the previously listed conditions have been met."
3. An appeal determination shall
be processed and approved or denied by the Administrator in accordance with
this section. At the discretion of the Administrator, an incomplete appeal may
be considered in accordance with this section.
4. A determination by the Administrator
becomes final under the appeal process and shall be effective retroactively to
the date of the original prescription.
5. Any party feeling aggrieved by the Order
of the Administrator has the right to appeal the final decision of the
Administrator to an Administrative Law Judge of the Arkansas Workers'
Compensation Commission for an expedited hearing. The appeal must be made
within 10 business days. The Administrative Law Judge shall have
two
weeks from receipt of the appeal to conduct an expedited hearing and
render a decision. The Notice of Appeal shall contain the following:
(a) A copy of the Administrator's Order
appealed from;
(b) Copies of all
materials submitted to the Administrator in the appeal proceedings.
Part VII.
Rule Review
The Arkansas Workers' Compensation Commission encourages
participation in the development of and changes to this Rule by all groups,
associations, and the public. Any such group, association or other party
desiring input or changes made to this Rule and associated schedules must make
their recommendations, in writing to the Medical Cost Containment
Administrator. After yearly analysis, the Commission may incorporate such
recommended changes into this Rule.
Part
VIII.
Effective Date of Rule
This Rule is adopted for all prescriptions for workers'
compensation claims with a date of injury on or after July 1, 2018,
and applies to all FDA approved drugs that are prescribed and dispensed
for outpatient use.