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Drug Formulary

Drug Formulary FAQ

Background

  • What is the formulary?
    The formulary is a list of drugs prescribed for the treatment of work-related injuries and occupational diseases. Drugs listed in the formulary are assigned “Y” or “N” status.
  • What is the purpose of the formulary?
    The purpose of the formulary is to facilitate the safe and appropriate use of prescription drugs in the treatment of work-related injuries and occupational diseases.
  • Why has the Department established the formulary?
    House Bill 2 of the 2018 Session of the General Assembly required the commissioner of the Department of Workers’ Claims to adopt a pharmaceutical formulary for medications prescribed for the cure of and relief from the effects of a work injury or occupational disease, and to promulgate administrative regulations to implement the formulary on or before December 31, 2018.
  • What is the difference between a “Y” drug and an “N” drug?
    Drugs assigned “Y” status (preferred drugs) may be dispensed without preauthorization and do not require utilization review. Drugs assigned “N” status (non-preferred drugs) require preauthorization.
  • How is the status of a drug determined?
    Evidence-based medicine and research support the assignment of a drug’s status. Drugs assigned “Y” status have been determined to be appropriate first-line treatment for work-related injuries and occupational diseases.
  • Who determines the status of a drug?
    The formulary adopted by the Department of Workers’ Claims is produced and published by ODG by MCGHealth, an organization that conducts and reviews appropriate medical research in determining the status of a drug.
  • Where can I find the formulary?
    The formulary is available to the public online at www.odgbymcg.com/state-formulary.


Important Formulary Dates

  • What are application dates of the formulary?
    1. For injuries and last exposures occurring on or after January 1, 2019 the formulary guidelines will apply to all prescriptions written on or after July 1, 2019.
    2. For injuries and last exposures occurring prior to January 1, 2019 the formulary guidelines will apply as follows:
      1. For a prescription that is not a refill prescription the formulary applies July 1, 2019;
      2. For a refill prescription of a drug initially prescribed prior to July 1, 2019, the formulary applies January 1, 2020.

  • What is the definition of a refill?
    "Refill" means a prescription for the same drug, at the same dose or strength, and in the same quantity and frequency and with the same instructions as was initially prescribed.
    It should be noted that Federal and Kentucky prescribing laws and rules limit the dispensing of controlled substances to certain monthly supplies and post-dated prescriptions. Prescriptions of controlled substances are considered refills if characteristics of the prescription otherwise match those listed above.
  • Why do claims have a bifurcated application date for the drug formulary regulations?
    To allow prescribers and injured workers' a longer period of time to discuss and consider alternative options for ongoing and long term treatments.


Preauthorization

  • What is preauthorization?
    Preauthorization means the process whereby payment for a medical service or course of treatment is assured in advance by the insurance carrier.
  • What happens when you do not receive preauthorization?
    The medical provider who has requested preauthorization may request a reconsideration of the preauthorization denial and may request a peer-to-peer telephone conference with the reviewing physician. Denials at the preauthorization stage may occur for reasons unrelated to medical necessity, such as lack of work-relatedness or non-compensability of the claim.


Utilization Review

  • What is the difference between preauthorization and utilization review (UR)?
    Preauthorization is defined in the section above. Utilization review means a review of the medical necessity and appropriateness of medical care and services for purposes of recommending payments for a compensable injury or disease.


Medications Covered by the Drug Formulary

  • What drugs are subject to preauthorization requirements?
    The drug formulary utilizes the most current ODG by MCG formulary as the basis for determining which drugs require preauthorization.
    “N” drugs as well as compounds, drugs dispensed for outpatient use by any person other than a pharmacist and any prescription drug not listed in the formulary require preauthorization. Insurers may approve “N” drugs without requiring preauthorization in circumstances where the insurer has previously reviewed and approved these medications.
  • What if a drug is not included in the formulary?
    Drugs not listed in the formulary require preauthorization.
  • Are “Y” drugs subject to preauthorization?
    No.
  • What if I am taking an “N” drug now?
    Consult with your medical provider to determine if changing to another medication may be appropriate. Failing to substantiate the need for the medication will result in future denial.
  • May a “Y” drug be submitted for Utilization Review?
    Yes. A “Y” drug may be submitted for utilization review to determine appropriateness and medical necessity for the involved condition. This provision, however, should not be used prospectively or if the prescription may be covered under the provisions listed below. It is the intent of the Department to avoid undue delays in the provision of “Y” drugs.


Prescriptions within Seven Days from Date of Injury (DOI)

  • Is there a new rule regarding drugs prescribed within seven days of the date of injury?
    Yes. An employer or its payment obligor is liable for payment of up to a seven (7)-day supply of a “Y” drug dispensed to or prescribed for an injured employee within seven (7) days of a work-related injury in treatment of that work-related injury even if the employer ultimately denies liability for the claim.
  • Does this include “Y” and “N” drugs?
    No. This rule applies only to “Y” drugs.
  • If the first fill prescription is written for more than seven days’ worth of a medication, is the prescription still valid?
    Yes, the prescription is valid, but the payer is responsible only to reimburse seven days of the prescribed medication whether or not the claim turns out to be compensable. If the claim is compensable, the carrier shall pay for the full prescription as long as the medication was prescribed in accordance with treatment guidelines.


Contact Information

For more information about the formulary regulation contact John Mann at 800-554-8601 or JohnW.Mann@ky.gov.

Support and training is also available through the ODG Helpdesk at 800-488-5548 or online at odghelp@mcg.com.