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Texas Department of Insurance Division of Workers’ Compensation

Texas Department of Insurance Division of Workers’ Compensation. Pharmacy Closed Formulary Stakeholder Meeting August 20, 2009. Agenda. Introductions Overview of the Informal Working Draft Rules Stakeholder discussion based on Informal Working Draft Rule topics Next Steps.

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Texas Department of Insurance Division of Workers’ Compensation

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 Informal Working Draft Rules • §134.500 Definitions • §134.506 Outpatient Drug Formulary (Proposed to be Repealed) • §134.507 Outpatient Drug Formulary - Closed • §134.508 Use of the Closed Drug Formulary for Claims Not Subject to Certified Networks • §134.509 Use of the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

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