California Division of Workers’ Compensation Releases New MTUS Formulary Rules

Listening to Feedback

On Tuesday, July 18, 2017, the California Department of Workers’ Compensation (DWC) released the modified version of the MTUS- Formulary rules incorporating many of the comments and suggested changes submitted during the initial comment period.

The rules go on to add several requirements that a prescribing physician must satisfy if they are prescribing a Non-Exempt medication to an injured worker with a date of injury prior to January 1, 2018. For any injured worker falling into this pre-2018 category, the physician must submit a progress report and a Request for Authorization that addresses the ongoing drug treatment plan for the injured worker. That treatment plan must either:

  1. set forth a plan for the safe weaning, tapering, or
  2. transitioning of the Non-Exempt medication or it must provide documentation that supports and substantiates the medical necessity of the Non-Exempt medication.

This process must be complete no later than April 1, 2018.

Educating prescribers on this requirement and helping them to develop safe weaning plans will be challenging given the short timeframe. Payers should begin proactively identifying claims with Non-Exempt drugs to understand the scope of the issue in their book of claims.

Delayed IMPLEMENTATION and Other Notable changes

Other key modifications in the proposed rules include:

  • The effective date of the formulary has changed from July 1, 2017 to January 1, 2018.
  • The use of the nomenclature “Preferred/Non-Preferred” has been changed throughout the rules and replaced by the terms “Exempt/Non-Exempt” to better represent the selection of medication that are “exempt from the utilization review process.
  • The Non-Exempt drug list only changed slightly, as two antibiotics were changed from Non-preferred to Exempt and one injectable drug was deleted from the list.
  • Updated the definition of “compounded drug” to link it to definitions already found in the California Board of Pharmacy regulations and under federal compounding laws.
  • The preauthorization requirement was strengthened through the removal of the following language throughout multiple sections:

“If authorization through prospective review is not obtained prior to dispensing the drug, payment for the drug may be denied if it is determined upon retrospective review that the drug treatment was not medically necessary.”

The most material change to the rules is found in Section 9792.27.3(b) dealing with the Formulary Transition, which removes some of the ambiguous language and adds several paragraphs on how the transitioning of claims with Non-Exempt drugs should be done. The following language was removed:

“The claims administrator shall not unilaterally terminate or deny previously approved drug treatment. If the injured worker is receiving a course of treatment that includes a Non-Preferred Drug, an unlisted drug or a compounded drug, the existing procedures for submitting the treatment plan in accordance with MTUS regulations, and for obtaining authorization for the treatment in accordance with utilization review regulations, shall apply.”

Also hosted on the California MTUS webpage is a Notice and Summary of Changes as well as the Proposed MTUS drug list. Should your organization have any interest in discussing how these changes might impact your book of claims, PRIUM’s Litigation Support team would look forward to having that conversation.  Contact us here:  

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