By Brian Allen, VP of Government Affairs
On December 7, 2017, the California Office of Administrative Law formally accepted and published the MTUS Drug Formulary rule without any changes from the final rule submitted by the Division of Workers’ Compensation (DWC). The rule is now set to go into effect on January 1, 2018. To learn more about the impact and provisions of the rule, read our previous post here.
Employers and insurers should be preparing for the implementation of the new formulary in a number of ways.
First, payors should:
- Make certain that their pharmacy benefit manager (PBM) is ready to go live with the new formulary on January 1, 2018, for all new claims.
- Talk to their PBM to see if there are other ways they can maximize the value of the new formulary.
- Verify that appropriate utilization review protocols are in place that comply with the requirements of the MTUS Drug Formulary rule and SB1160, legislation that passed in 2016.
Following these initial actions, there are several other considerations and changes to make. For claims with dates of injury prior to January 1, 2018, payors should be working with their PBM to determine which injured workers are receiving medications that are not listed as “exempt” in the MTUS Drug Formulary. For injured workers receiving non-exempt or unlisted medications, a plan should be in place prior to April 1, 2018. This plan should either detail how the physician plans to transition the injured worker to exempt medications or contain approved prior authorization requests to continue prescribing the non-exempt or unlisted medication for a specified period. We highly recommend that payors, either on their own or through their PBM, reach out to prescribing physicians and injured workers to inform them of the changes and encourage them to develop a plan well in advance of the April 1, 2018, deadline.
Finally, we recommend that all stakeholders document their experience with the new formulary and provide both good and bad feedback to the DWC. This will help the DWC to reinforce those areas that are working as intended and to make appropriate adjustments in the areas that aren’t achieving the hoped for results. We appreciate the open process employed by the DWC during the rulemaking and their response to our feedback. We know that they will appreciate on-going constructive feedback as the MTUS Drug Formulary is rolled out.
Mitchell is committed to doing all that we can to help our customers with a smooth transition to the new formulary and our programs are ready for the January 1, 2018, start date. For any Mitchell customer with additional questions, please contact your Client Services Manager.
For questions about the MTUS Drug Formulary rule or other legislative or regulatory action, please contact Brian Allen, Vice President of Government Affairs at Brian.Allen@mitchell.com or via telephone at 801.661.2922.