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Montana workers’ comp formulary adopted

by
Optum Workers' Comp
| Dec 19, 2018

The Montana Department of Labor and Industry has formally adopted regulations to implement a workers’ compensation outpatient drug formulary. This final action follows many meetings with stakeholders over the course of approximately two years and a more recent formal rule-making period in connection with the 2017 passage of Senate Bill 312, which granted the department the authority to adopt a formulary.

The adopted rule language largely mirrors the language they proposed back in October with only a few modifications. The department has adopted the Official Disability Guidelines (ODG) Drug Formulary as their formulary source; however, they will maintain their existing utilization and treatment guidelines rather than adopting ODG’s treatment guidelines.

Prior authorization under the formulary

Under the adopted formulary rules, prior authorization will be required for ODG “N” status medications, unlisted medications, experimental or investigational medications and compounded medications (even if all of the components of the compound are listed as ODG “Y” status). However, prior authorization will not be required for an “injury appropriate” medication if the medication is listed as “Y” or if the medication is listed as “N” and the prescription is written within seven days of the occurrence of the workplace injury and limited to a maximum of a seven-day supply.

Two-phased implementation of the formulary

The formulary will take a two-phased implementation approach to ensure injured workers are not abruptly cut off from medications. Initially, the formulary will apply to all claims arising on or after April 1, 2019. Claims arising before April 1, 2019 are referred to as “legacy” claims. For those legacy claims, the formulary will take effect for any prescriptions written on or after April 1, 2020 or 90 days after the insurer gives notice compliant with the rules, whichever comes last. A compliant notice should consist of written notice to the injured worker and the treating physician that the claim constitutes a legacy claim in which the insurer will enforce the applicability of the formulary (certain minimum contents are required). The adopted rules also state that part of the treating physician’s responsibilities for handling legacy claims is to determine whether a transition plan is needed for the affected injured worker and to communicate this to the insurer.

Process adjustments

Now that the final rules have been adopted, our OWCA Regulatory Implementations team will be moving forward with impacted internal departments, including our clinical experts, to implement the new formulary into our processes. As the development efforts progress, additional communications keeping our clients updated should follow. Formal publication of the adoption notice in the Montana Administrative Register is expected on December 21 and will be posted here. In the meantime, we encourage our clients to review several other resources provided by the state, which are available on the department’s website here.

OWCA advises Montana Department of Labor and Industry

The Optum Workers’ Comp and Auto No-fault Government Affairs team was part of a group of stakeholders advising the department during rule development. Should you have any questions on the intent or the requirements of the new rules, please feel free to contact our Government Affairs team at AskGovtAffairs@optum.com.



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