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(a)The commission hereby adopts an open formulary as defined in Section 134.500(a)(4). The carrier shall pay for drugs that are reasonable and medically necessary to treat the compensable injury or occupational disease. The insurance carrier may pay for prescriptions for off label indications when used in accordance with current medical standards and prescribed in compliance with published contradictions, precautions, and warnings. (1)Over-the-counter medications with a prescription shall be reimbursed. (2)The carrier may consider temporary coverage of prescriptions for conditions not related to the compensable injury when such medications are necessary to promote recovery of the compensable injury. (b)The carrier shall pay for detoxification and/or chemical dependency treatment in the following circumstances: (1)The injured employee becomes dependent or toxic due to medication prescribed for a compensable injury; (2)The injured employee becomes dependent or toxic due to medications prescribed for a condition not related to the compensable injury in order to promote recovery of the compensable injury; or, (3)The injured employee is dependent or toxic due to medications for an unrelated condition, but that dependency or toxicity is retarding recovery of the compensable injury. (c)Additional Information: (1)When a spinal cord injury is the compensable injury, the carrier may authorize payment for anti-spasticity medication by any indicated route of administration. (2)Prescriptions for injectable opioids or other injectable analgesics, sedatives, antihistamines, tranquilizers, psychotropics, vitamins, minerals, food supplements, and hormones are not routinely reimbursed. (3)The carrier may pay for injectable medications under the following circumstances: (A)Inpatients; (B)During emergency treatment of a life-threatening condition/injury; (C)During outpatient treatment of severe soft tissue injuries, burns, or fractures when needed for dressing or cast changes; or, (D)During the preoperative period and the postoperative period, not to exceed forty-eight hours from the time of discharge. (4)The carrier may pay for prescriptions of injectable insulin, heparin, anti-migraine medications, or impotency treatment, when reasonable and medically necessary. (5)Payment of prescriptions for benzodiazepines are limited to the following types of patients: (A)Hospitalized patients; (B)Claimants with an accepted psychiatric disorder for which benzodiazepines are indicated; (C)Claimants with an unrelated psychiatric disorder that is retarding recovery but which the carrier has temporarily authorized treatment and for which benzodiazepines are indicated; and, (D)Other outpatients for not more than thirty days over the life of the claim. (6)When cancer or any other end-stage disease is the compensable injury, the carrier may authorize payment for any indicated scheduled drug and by any indicated route of administration. (d)The carrier may take any or all of the following steps when concerned about the amount or appropriateness of drugs the patient is receiving: (1)Notify the prescribing doctor, injured employee, and pharmacy of concerns regarding the medications such as drug interactions, adverse reactions, and prescriptions by other providers; (2)Require that the prescribing doctor send a statement of medical necessity addressing the drug concerns; (3)Request a consultation from a required medical exam (RME) doctor; (4)Request that the prescribing doctor consider reducing the prescription and provide information on chemical dependency programs; or, (5)Limit the payment for drugs on a claim to one prescribing doctor. (e)When a doctor has placed an injured employee on a routine, regularly observed regimen of prescription drugs, the carrier may only discontinue payment for one or more drugs in the regimen after adequate prior notification of 15 days has been given to the employee, pharmacy, and doctor. The commission may prescribe the form and manner of notification.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on August 20, 2001
TRD-200104908 Susan Cory
General Counsel
Texas Workers' Compensation Commission
Earliest possible date of adoption: September 30, 2001
For further information, please call: (512) 804-4287
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