Texas Department of Insurance Division of Workers Compensation

1
Texas Department of InsuranceDivision of
Workers Compensation

• Pharmacy Closed Formulary
• Stakeholder Meeting
• August 20, 2009

2
Agenda

• Introductions
• Overview of the Informal Working Draft Rules
• Stakeholder discussion based on Informal Working
  Draft Rule topics
• Next Steps

3
Informal Working Draft Rules

• 134.500 Definitions
• 134.506 Outpatient Drug Formulary (Proposed to
  be Repealed)
• 134.507 Outpatient Drug Formulary - Closed
• 134.508 Use of the Closed Drug Formulary for
  Claims Not Subject to Certified Networks
• 134.509 Use of the Closed Drug Formulary for
  Claims Subject to Certified Networks

4
Clarifications and Revisions

• Clarifications
• Statutory Definitions
• Labor Code
• Occupations Code
• Rule References
• Coordination of Statutory and Rule language
• Existing language
• Revisions
• Restricted preauthorization to N drugs

5
IWDR Closed Formulary (informal rule)
Closed Formulary includes ALL FDA approved drugs
except
Compounds that include drugs w/ status N
Investigational or Experimental Drugs
Drugs w/ status N
6
ODG Appendix A (example)
7
Basic Decision Tree
NO
NO
NO
Closed Form Apply to DOI?
Initial Fill?
Preauth 413.014?
Yes
Yes
Yes
Fill Script
Preauthorization Reconsideration MDR-IRO
Yes
N Drug?
NO
Retrospective Review
Fill Script
8
Commenter topics

• Initial Pharmaceutical Coverage
• Retrospective Review
• N drug prescriptions
• Phase in/Applicability

9
Total N Drug Prescriptions for CY 2007 by
Injury Year
Total N Drug prescriptions 183,543
10
Estimated total N Drug preauthorizations for
new injuriesduring the initial twelve months of
rule applicability
Estimated Total First year N Drug prescriptions
20,457
11
Estimated total N Drug preauthorizations for
new and legacy claimsduring the initial twelve
months of rule applicability
12
Legacy claims with prescription activity in CY
2008
13
Next Steps

• Finalize Proposal
• Posting in the Texas Register
• Public Comment
• Adoption
• Implementation