The medical treatment guidelines "are not standards that must be followed, but guidelines to improve medical care," noted the TN BWC. Many of those in the workers' comp industry, including carriers, providers, and case managers, are familiar with the guidelines. Companies conducting utilization reviews already refer to ODG when determining whether to approve or deny treatment requests.
RX Formulary:
The formulary is a "closed formulary" that includes all available Food and Drug Administration (FDA) approved prescription and nonprescription drugs prescribed and dispensed for outpatient use. Categories of medications listed below require prior approval:
- Drugs identified with a status of "N" in the current edition of the ODG Appendix A, ODG Workers' Compensation Drug Formulary, and any updates;
- any compound or topical medication; and
- any investigational or experimental drug that has not yet been identified as a "Y" or "N" drug for which there is early, developing scientific, or clinical evidence demonstrating the potential efficacy of the treatment, but which is not yet accepted as the prevailing standard of care.
The goal of the formulary and medical treatment guidelines is decreased opioid use in work comp claims along with lower costs for employers. Many insurance carriers are familiar with both formularies and the use of medical treatment guidelines from their work in jurisdictions already utilizing the tools.
EK will continue to monitor the changes as they are implemented and will work closely with our clients, Third Party Administrators and Pharmacy Benefit Managers to ensure compliance.
For more information, please contact Demetria Woodson, Manager of Compliance and Regulations at
dwoodson@ekhealth.com.
