Tenn. Comp. R. & Regs. 0800-02-25-.04 - DRUG FORMULARY
(1) The purpose of
the drug formulary is to facilitate the safe and appropriate use of medications
for injured workers, and is a specific part of the Treatment Guidelines set
forth in subsection .03 of this rule.
(2) The Bureau adopts the ODG Drug Formulary
as found in Drug Appendix A published and updated by the Work Loss Data
Institute. When the Work Loss Data Institute releases an updated ODG Drug
Formulary, or amends any element of the current ODG Drug Formulary, the Medical
Director, in consultation with the Medical Advisory Committee, shall review all
such updates and amendments on a semi-annual or annual basis as deemed
appropriate by the Medical Director, and report to the Administrator the
impact, if any, of such updates or amendments on the continuing viability of
the ODG Drug Formulary for use in Tennessee. The Administrator will include any
such pertinent information and/or recommendations in the Bureau's annual report
to the general assembly.
(3)
Prescriptions presented to a pharmacy from an authorized provider and
appropriate for the prescribed injury within seven (7) days of an alleged or
accepted workers' compensation claim may be filled for a maximum of seven (7)
days, even if the prescribed medication is status "N." The employer is
responsible for the payment.
(4)
The Formulary shall be made available by posting on the Bureau's website.
Subsequent updates shall be effective on the first day of the month following
posting of an update on the Bureau's website.
(5) Drugs identified with the status "N" in
the current edition of the ODG/Appendix A, and any other related appendices
adopted by the Administrator in effect at the date the treatment is
recommended, shall require prior approval. An "N" drug should not be approved
unless its use in a particular case is supported by documentation of
evidence-based medicine.
(6)
Compounded medications and topical applications are "N" and subject to prior
approval. An "N" drug should not be approved unless its use in a particular
case is supported by documentation of evidence-based medicine.
(7) Prescriptions for "Y" drugs should be
filled without delay if they are approved as appropriate for the nature of the
injury being treated.
(8) For
compensation claims with a date of injury (DOI) on or after January 1, 2016,
and for new medication prescriptions for dates of injury prior to January 1,
2016, the formulary applies to all drugs that are prescribed or dispensed for
outpatient use on or after six-months following the effective date of these
rules.
(9) For refill prescriptions
and medications being used for dates of injury (DOI) before January 1, 2016,
the formulary applies to all drugs that are prescribed or dispensed for
outpatient care one year from the effective date of these rules.
(10) Retrospective review of medications will
be allowed only for drugs that are not appropriate for the injured worker's
diagnosis. Only the next refill prescribed by the authorized treating physician
can be denied.
(11) The following
words and terms, when used in this subchapter, have the following meanings,
unless the context clearly indicates otherwise:
(a) "Closed Formulary" means all available
Food and Drug Administration (FDA) approved prescription and nonprescription
drugs prescribed and dispensed for outpatient use, and applies to the
categories listed below that require prior approval:
1. Drugs identified with a status of "N" in
the current edition of the Official Disability Guidelines Treatment in Workers'
Compensation (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary, and
any updates;
2. Any compound or
topical; and
3. Any investigational
or experimental drug that has not yet been identified as a "Y" or "N" drug for
which there is early, developing scientific or clinical evidence demonstrating
the potential efficacy of the treatment, but which is not yet accepted as the
prevailing standard of care.
(b) "Compounding", "compound" or "compounded"
medication or preparation means the preparation, mixing, assembling, packaging,
or labeling of a drug or device:
1. As the
result of a practitioner's prescription drug order based on the
practitioner-patient-pharmacist relationship in the course of professional
practice;
2. For administration to
a patient by a practitioner as the result of a practitioner's initiative based
on the practitioner-patient-pharmacist relationship in the course of
professional practice;
3. In
anticipation of a prescription drug order based on a routine, regularly
observed prescribing pattern; or
4.
For or as an incident to research, teaching, or chemical analysis and not for
selling or dispensing.
(c) "Evidence-based ", medicine" (EBM) means
an approach to medical practice intended to optimize decision-making by
emphasizing the use of evidence from well-designed and well- conducted
research, to include the integration with clinical expertise and patient values
and an evolutionary progression of knowledge based on the basic and clinical
sciences.
(d) "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.
(e)
"Medical emergency" means the sudden onset of a medical condition manifested by
acute symptoms of sufficient severity, including severe pain that in the
absence of immediate medical attention could reasonably be expected to result
in:
1. Placing the patient's health or bodily
functions in serious jeopardy; or
2. Serious dysfunction of any body organ or
part.
(f)
"Nonprescription drug" or "over-the-counter medication" means a non-narcotic
drug that may be sold without a prescription and that is labeled and packaged
in compliance with state or federal law.
(g) "Open Formulary" means all available Food
and Drug Administration (FDA) approved prescription and nonprescription drugs
prescribed and dispensed for outpatient use, but does not include drugs that
lack FDA approval, or non-drug items.
(h) "Prescribing Doctor" means a physician or
dentist who prescribes prescription drugs or over the counter medications in
accordance with the physician's or dentist's license and state and federal laws
and rules. For purposes of this chapter, prescribing doctor includes an
advanced practice nurse or physician assistant to whom a physician has
delegated the authority to carry out or sign prescription drug orders, who
prescribes prescription drugs or over the counter medication under the
physician's supervision and in accordance with the health care practitioner's
license and state and federal laws and rules.
(i) "Prescription" means an order for a
prescription or nonprescription drug to be dispensed, in accordance with the
applicable federal definition and in T.C.A. Title 53 Chapter 10.
(j) "Prescription drug" means:
1. A substance for which federal or state law
requires a prescription before the substance may be legally dispensed to the
public;
2. A drug that under
federal law is required, before being dispensed or delivered, to be labeled
with the statement: "Caution: federal law prohibits dispensing without
prescription;" "Rx only;" or another legend that complies with federal law;
or
3. A drug that is required by
federal or state statute or regulation to be dispensed on prescription or that
is restricted to use by a prescribing doctor only.
(k) "Substitution" means the dispensing of a
drug or a brand of drug other than the drug or brand of drug ordered or
prescribed.
(l) "Topical" means a
prescription substance or substances, not injected or ingested, that are used
on the skin or other membranes, or are applied to exterior or exposed surfaces.
This category includes "inhalers."
(12) The provider may appeal to the Bureau's
Medical Director for an expedited decision, using a request for an expedited
determination.
(a) The purpose of this section
is to provide a prescribing doctor or pharmacy the ability to obtain an
expedited determination from the Bureau's Medical Director in instances where a
denial of a previously prescribed and dispensed drug(s) for the workers'
compensation injury poses an unreasonable risk of a medical emergency as
defined in this title.
(b) The
request for an expedited determination from the Medical Director may be
rejected at the sole discretion of the Medical Director if it does not contain
the following information:
1. Injured employee
name;
2. Date of birth of injured
employee;
3. The injured employee's
Social Security Number.
4.
Tennessee Bureau of Workers' Compensation state file or claim number;
5. Date of injury;
6. Prescribing doctor's name;
7. Prescribing doctor's DEA number;
8. Name of drug and dosage;
9. Requestor's name (pharmacy or prescribing
doctor);
10. Requestor's contact
information;
11. A statement that
the prior approval request for a previously prescribed and dispensed drug(s),
which is excluded from the Closed Formulary, has been denied by the insurance
carrier, accompanied by the denial letter if available;
12. A statement that an independent review
request or request for reconsideration has already been submitted to the
insurance carrier or the insurance carrier's utilization review
agent;
13. 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;
14. A statement that the potential medical
emergency has been documented in the prior approval process;
15. A statement of justification from a
medical perspective of the potential medical emergency such as withdrawal
potential or other significant side effects or complications;
16. A statement that the insurance carrier
has been notified that a request for an expedited determination is being
submitted to the Bureau; and
17.
The signature of the requestor and the following certification by the requestor
for paragraphs 10 to 14 of this subsection, "I hereby certify under penalty of
law that the previously listed conditions have been met."
(c) A request for an expedited determination
under this section shall be processed and approved by the Medical Director of
the Bureau in accordance with this section. At the discretion of the Medical
Director of the Bureau, an incomplete request or a request with incomplete
information for an expedited determination under this section may be considered
in accordance with this section.
(d) The request for an expedited
determination may be submitted on the designated form available on the Bureau
of Workers' Compensation website. In the event the Bureau form is not
available, the written request should contain the provisions of subsection (b)
of this section.
(e) The requestor
shall provide a copy of the request to the insurance carrier, prescribing
doctor, injured employee, and dispensing pharmacy, if known, on the date the
request is submitted to the Bureau.
(f) An expedited determination shall be
effective retroactively to the date of the original prescription.
(13) A request for reconsideration
of a prior approval denial is not required prior to a request for an expedited
determination under this section. If, within 15 business days from the initial
prior approval denial, a request for reconsideration or an expedited
determination request is not initiated within 15 business days by the provider
to the employer, carrier or utilization review agent and an expedited
determination request is not communicated by the provider to the Medical
Director of the Bureau at that time, then the opportunity to request an
expedited determination under this section does not apply. Additionally, where
a health care provider has sought relief from a previous adverse determination
by requesting reconsideration by the employer, carrier, or utilization review
agent and also by requesting an expedited determination by the Medical
Director, the determination of the Medical Director shall prevail over the
reconsideration determination of the employer, carrier, or utilization review
agent.
(14) If pursuing an
expedited determination after denial of a reconsideration request, a complete
request shall be submitted within five business days of the notification of the
reconsideration denial.
(a) An appeal of the
utilization review organization decision relating to the medical necessity and
reasonableness of the drugs contained in the expedited determination shall be
submitted in accordance with these rules.
(b) The Medical Director's determination
shall continue in effect until the later of:
1. Final determination of a medical dispute
regarding the medical necessity and reasonableness of the drug;
2. Expiration of the period for a timely
appeal; or
3. Agreement of the
parties.
(c) Withdrawal
of the request for an expedited determination by the requestor constitutes
acceptance of the prior approval denial.
(d) All parties shall comply with an
expedited determination issued in accordance with this section and the
insurance carrier shall reimburse the pharmacy or other payer for prescriptions
dispensed in accordance with the determination of the Medical
Director.
(e) The insurance carrier
shall notify the prescribing doctor, injured employee, and the dispensing
pharmacy once reimbursement is no longer required because of the denial by the
Medical Director of a request for an expedited determination.
(f) A decision issued by a utilization review
organization is not a Bureau decision.
(g) A party may seek to reverse or modify the
Medical Director's determination issued under this section if:
1. A final determination of medical necessity
has been rendered; and
2. The party
requests a hearing in accordance with the procedures of the Court of Workers'
Compensation Claims.
3. The
insurance carrier may dispute the request for expedited determination or the
Medical Director's determination entered under this title by filing a written
request for a hearing in accordance with the Court of Workers' Compensation
Claims procedures.
Notes
Authority: T.C.A. ยงยง 50-6-122, 50-6-124, 50-6-125, 50-6-126, and 50-6-233.
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