Drug Formularies: One size fits all?

Released: 09/28/2020  

Prescription drug payments comprise a substantial portion of medical expenditures for workers compensation (WC) claims.  For Accident Year 2016, prescription drug payments represented approximately 14% of the ultimate total medical costs.  Regulation of prescription drug prices and utilization of prescription medications have recently become a focus of legislative activity in WC as states grapple with high prescription drug costs and the opioid crisis.

A WC prescription drug formulary is utilized to ensure medically necessary injury related medications are provided without a difficult authorization process. Different formularies should be considered based on the industry and the amount of time post injury such as: 1) First-fill and Acute Phase Formulary, 2) Sub-acute Formulary and 3) Chronic Formulary. Many states as well as evidence-based medicine authorities have followed suite.

An example of a published formulary is the Official Disability Guidelines (ODG) Formulary which is part of the evidence‐based treatment guidelines (the ODG Guidelines).  Within a formulary, medications are classified with status indicators that identifies any drug that requires prior authorization. Drugs with a status indicator of “N” (N‐drugs), not included, require prior authorization by the employer or WC insurer, while drugs with a status indicator of “Y” (Y‐drugs), included, do not require prior authorization.

Carlisle Medical has over 40 years of experience in formulary development and management. The recommended standard WC formulary is composed mainly of medications in the therapeutic classes of Analgesics, Antibiotics, Nonsteroidal Anti-inflammatory Drugs (NSAIDs), and Muscle Relaxants. A formulary is not a “one size fits all” and Carlisle Medical has the experience to customize a formulary. Each of our customer’s formularies are developed to provide the safest, most appropriate, and cost-effective treatment possible. A formulary is a management tool that can meet the specific needs of a customer based on industry and injury type.

Formularies are reviewed and updated with our clinical team and customers regularly to reflect current market conditions and new generic releases. Each medication included in the formulary is evaluated on effectiveness, safety and price, relative to other medications on the market. Ultimately, Carlisle Medical strives to mitigate risk and lower costs through the appropriate use of formularies.

Carlisle Medical is prepared to assist with your formulary needs. Please call today at 1-800-553-1783 or visit our contact us to learn more about our service offering.


Sources: Formulary Implementations and Initial Impacts on Workers Compensation: https://www.ncci.com/Articles/Pages/Insights-Formulary-Implementations-Initial-Impacts-WorkersComp.aspx