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You are here: www.tdi.texas.gov . wc . pharmacy . index

Pharmacy

In the Texas workers' compensation system, pharmacy benefits are based on a series of rules entitled Pharmaceutical Benefits [28 Texas Administrative Code (TAC) §134.500 through §134.550]. These rules cover commonly used definitions, initial pharmaceutical coverage, prescribing of generics and over-the-counter drugs in addition to brand name drugs, a pharmacy fee guideline, open and closed formularies, rules pertaining to the transition to a closed formulary from an open formulary, and other pharmaceutical provisions. Understanding the rules for pharmacy services and related resources are crucial to the clinically appropriate prescribing of prescriptions and successful reimbursement for both claims subject to certified workers' compensation health care networks (networks), and claims not subject to certified networks (non-network).

Appendix A | Recent Items | Pharmacy Rules | Pharmacy Closed Formulary Rule Development and Implementation | Related Links

Appendix A

"N" Drugs in Official Disability Guidelines - Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary

The Division of Workers' Compensation (DWC) has posted Appendix A, ODG Workers' Compensation Drug Formulary, from the Official Disability Guidelines - Treatment in Workers' Comp (ODG) . The DWC will update the listing monthly upon receipt from ODG. The online edition of the ODG is updated as new evidence becomes available and is the official source for DWC actions.

Recent Items

Pharmacy Closed Formulary Diagram

Pharmacy Closed Formulary Diagram

As of September 1, 2013, the pharmacy closed formulary applies to all claims regardless of date of injury. Pharmacy closed formulary includes all FDA approved drugs. Preauthorization is required for drugs identified with a status of "N" in the current edition of the ODG , any compound that contains a drug identified with a status of "N", and any investigational or experimental drug as defined in Texas Labor Code §413.014(a).

Pharmacy Closed Formulary Bifurcated Timeline

Pharmacy closed formulary critical milestone dates based on the adopted rules.

Pharmacy closed formulary critical milestone dates are based on the adopted rules. Using a single track line, the first milestone is the start date of January 17, 2011, which is the effective date of the open formulary. The next milestone is September 1, 2011, and shows the rules taking two tracks. One track is the continuation of the open formulary for dates of injury prior to September 1, 2011, also termed "legacy" claims. The second track is the effective date of the closed formulary and medical interlocutory orders for dates of injury on or after September 1, 2011. The third and final milestone is September 1, 2013, which brings the closed formulary back to a single track line, showing the closed formulary to be applicable for all claims as of September 1, 2013 and beyond, regardless of dates of injury.

Pharmacy Rules:

Training Tools

Pharmacy Closed Formulary Rule Development and Implementation

2005

The 79 th Texas Legislature passed House Bill 7, which amended Texas Labor Code §408.028 concerning Pharmaceutical Services. The pertinent provisions stated: "The commissioner by rule shall adopt a closed formulary under Section 413.011. Rules adopted by the commissioner shall allow an appeals process for claims in which a treating doctor determines and documents that a drug not included in the formulary is necessary to treat an injured employee's compensable injury."

March 2008 - August 2010

  • Research and rule development
  • System participant meetings
    • August 25, 2008, March 5, 2009, and August 20, 2009
  • Informal working drafts of the rules published on the agency's website
    • December 16, 2008, June 12, 2009, and February 4, 2010
  • Rule proposal and public hearing
    • July 16, 2010, and August 16, 2010

December 2010

Rule adoption - http://www.tdi.texas.gov/wc/rules/adopted/documents/aorx1210.pdf

August 2011

Memo - Texas Workers' Compensation System Adopts Pharmacy Closed Formulary (PDF)

September 2011

Closed formulary applicable to new claims

July 2012

The DWC prepared sample notification letters for insurance carriers to consider when fulfilling the notification requirement of 28 TAC §134.510. This insurance carrier notification activity applied to the claims with dates of injury prior to September 1, 2011, referred to as legacy claims.

January 2013

Pharmacy Closed Formulary Status and Legacy Claim Implementation Reminders

July 2013

Notice of Pharmacy Closed Formulary Data Call on Legacy Claims ( Instructions, Spreadsheet)

August 2013

REMINDER-Pharmacy Closed Formulary Status and Legacy Claim Implementation

September 2013

Related Links

Informal/Voluntary Networks

Preauthorization

If you have questions, contact Comp Connection for Health Care Providers at 800-372-7713, option 3.



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Last updated: 09/25/2014

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