Tennessee Publishes Rules on Treatment Guidelines and Drug Formulary

Released: 02/19/2016   By: Allen McLean, Vice President

Tennessee Publishes Rules on Treatment Guidelines and Drug Formulary

The Tennessee Attorney General has approved new treatment guidelines and a closed drug formulary proposed by the Tennessee Bureau of Workers’ Compensation. The rule will next go before a legislative committee for review and approval. As published, the rule is scheduled to take effect on February 28, 2016, but depending on action of the legislature, it could be delayed for up to 30 days.

Rule Highlights

The treatment guidelines adopted in the rule are a combination of the Official Disability Guidelines (ODG), the Tennessee Department of Health Chronic Pain Guidelines, and related appendices of both guidelines, including any future updates. The guidelines apply to treatment occurring on or after January 1, 2016.

Injured workers with a date of injury on or after January 1, 2016 will be subject to the closed drug formulary six months after the effective date of the rule. For injuries that occurred prior to January 1, 2016, the formulary will apply six months following the effective date for newly prescribed medications, and 12 months after the effective date for any medications used by the injured worker prior to January 1, 2016.

The drug formulary is a “closed formulary” that includes all available FDA approved prescription and nonprescription drugs prescribed and dispensed for outpatient use. The 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 compounded or topical medication
•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

Drugs indicated with a “Y” status in Appendix A should be “filled without delay,” as long as the medication is appropriate for the injury. Prescriptions that are appropriate for a prescribed injury and are presented to a pharmacy from an authorized provider within 7 days of an alleged or accepted workers’ compensation claim may be filled for a maximum of 7 days, even if the prescribed medication is status “N,” and the employer is responsible for payment. Retrospective review of medications will be allowed only for drugs that are not appropriate for the diagnosis, and only the next refill prescribed by the authorized treating physician can be denied.

The rule also includes an expedited appeals process for physicians and pharmacies to use if they disagree with the denial of a medication.