For the past year the Department of Industrial Relations has been reviewing regulations to add to the Medical Treatment Utilization Schedule for purposes of regulating drug formularies within the Workers’ Compensation system. These regulations did take hold and went into affect as of January 1, 2018. That stated purpose for these regulations, “to provide critical support for the effort to encourage safer prescribing of opioid pain relievers” and to “significantly reduce the rate of opioid-related adverse events, substance misuse and abuse.”

The understanding and management of these regulations should also assist in claim management and reduce unwieldy costs associated with prescription drug misuse within the system. The following is a quick overview of some of the new regulations. The full text of each regulation can be viewed here:

https://www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Formulary/Final-Regulations/Text-Of-Regulations.pdf

Highlights –
Section 9792.27.1 – Definitions

“Dispense” means 1) the furnishing of a drug upon a prescription from a physician or other healthcare provider acting in the scope of his or her practice, or 2) the furnishing of drugs directly to a patient by a physician acting within the scope of his or her practice.

“Exempt Drug” meas a drug on the MTUS Drug List which is designated as being a drug that does not require authorization through prospective review prior to dispensing the drug, provided that the drug is prescribed in accordance with MTUS guidelines.

“MTUS Drug List” means the drug list and related information in section 9792.27.15 which sets forth the exempt or Non-Exempt status of drugs listed by active drug ingredients.

“Non-Exempt Drug” means a drug on the MTUS Drug List which is designated as requiring authorization through prospective review prior to dispensing the drug.

Section 9792.27.2 – Drugs prescribed or dispensed to treat a work related injury or illness fall within the definition of medical treatment and are subject to the MTUS. All drugs dispensed on or after 01/01/2018 for outpatient use are subject to the MTUS drug formulary.

Section 9792.27.3 – The MTUS Drug Formulary applies to drugs dispensed on or after January 1, 2018 regardless of the date of injury. There is a transition phase for those receiving ongoing drug treatment for dates of injury prior to 01/01/2018. For injured workers with dates of injury prior to 01/01/2018, their physician shall submit a progress report and RFA that addresses the need for medication and includes a treatment plan setting forth an appropriate weaning, tapering or transitioning of the worker to a drug pursuant to the MTUS.

Section 9792.27.7 – Where a physician prescribes a brand name drug when an equivalent generic drug exists (and writes “do not substitute” or “dispense as written”) the physician must document the medical necessity for prescribing the brand name drug and submit a Request for Authorization and obtain authorization through prospective review before the brand name drug is dispensed.

Section 9792.27.8 – Drugs dispensed by a physician must be authorized through prospective review prior to being dispensed (limited exceptions). A seven day supply can be dispensed if it has “Exempt” status and is dispensed at the time of an initial visit that occurs within 7 days of the date of injury.

Section 9292.27.9 – Compounded drugs must be authorized through prospective review prior to being dispensed.

Section 9792.27.15 – The MTUS Drug list can be found here:

http://www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Formulary/Final-Regulations/DRUG-LIST.pdf

With reports of approximately 62 deaths per day due to prescription opioids and the countless costs related to their misuse, I can only hope that these regulations with have an impact on the issue they attempt to address.