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Montana workers’ comp drug formulary formally proposed

by
Optum Workers' Comp
| Oct 22, 2018

The Montana Department of Labor and Industry has now formally proposed regulations to implement a workers’ compensation outpatient drug formulary. This action follows lengthy discussions and meetings with stakeholders on formulary development, in connection with the 2017 passage of Montana Senate Bill 312, granting the Montana Department of Labor and Industry the authority to adopt a drug formulary.

The department has chosen the Official Disability Guidelines (ODG) Drug Formulary. The proposed rules, initially, adopt the October 2018 edition of the ODG formulary, but state that automatic monthly updates are incorporated by reference, without additional rule-making. However, the department will maintain its existing utilization and treatment guidelines (with updates) rather than adopting the ODG medical treatment guidelines.

Formulary specifics

Under the proposed 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.

Formulary implementation

The formulary will take a two-phased implementation approach to ensure injured workers are not abruptly cut off from medications. Initially, the formulary is proposed to apply to all claims arising on or after April 1, 2019. Claims arising before April 1, 2019 are referred to as “legacy” claims. For 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. The proposed rules also note 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 communicating this  to the insurer.

OWCA Government Affairs team advises Montana Department of Labor and Industry

The Optum Workers’ Comp and Auto No-fault Government Affairs team has been part of a group of stakeholders advising the department during rule development. We applaud the department for including an array of knowledgeable and experienced stakeholders in that process, and we look forward to providing additional formal input during the formal rule-making period.

We encourage our clients to review the proposed formulary rules and provide feedback to the department. A public hearing will be held on November 9, 2018, and written comments will be accepted until November 16.

A copy of the proposed rules is available on the department’s websitehere. Should you have any questions on this or any other public policy development topics, please contact our Government Affairs team at AskGovtAffairs@optum.com.


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