A Look at What the New Worker’s Comp Drug Formulary Law Means for Indiana

Official Disability Guidelines (ODG) is a very extensively used and adopted worker’s compensation medical treatment, return-to-work and drug formulary guideline. ODG is evidenced-based and has impressive data analytics to back up those guidelines. Approximately 100 physicians of all medical specialties active in worker’s comp make up the ODG Editorial Board to advance evidence-based medicine to access quality care, limit inappropriate utilization and create clarity for medical clinicians.

Seventeen states, four Canadian provinces, the Bahamas and Puerto Rico have adopted ODG guidelines in some capacity. Other states have gone through the arduous and expensive task of creating their own guidelines. And 14 states have no guidelines or are considering implementation.

While a state may adopt all the evidence-based treatment guidelines provided by ODG, 2018 House Enrolled Act 369 only adopted the drug formulary for worker’s comp. Senator Randy Head (R-Logansport) authored the bill for the specific purpose of attempting to address the opioid epidemic in Indiana.  During session testimony, the Indiana Chamber cited Texas’ experience with the ODG drug formulary. Texas saw a significant reduction in both the cost of prescription drugs in worker’s comp claims and a reduction in opioid prescriptions.

Recently, the Indiana Chamber, the Worker’s Compensation Board and several other groups met with representatives from ODG and insurance carriers familiar with ODG to discuss implementation of HEA 369. Also present was the former Texas commissioner for worker’s comp who implemented ODG guidelines in that state.

While the statute goes into effect July 1, 2018, a drug that is listed on the drug formulary as a “N” drug and is prescribed on or after January 1, 2019 will not be eligible for reimbursement in a worker’s comp claim. However, if the employee was using an “N” drug prior to July 1, 2018 and is using the drug after January 1, 2019, reimbursement is still permitted until January 1, 2020.

Meanwhile, “N” drugs prescribed during a medical emergency are exempt from the reimbursement prohibition. Additionally, there may be cases when a prescribing physician believes it is necessary to prescribe the “N” drug. In such an instance, the physician submits a request to the employer with the reason for the request. (The Worker’s Compensation Board is determining whether there will be a universal form for the request and how that will be submitted.) If the employer doesn’t approve the request, there is a third-party review process for the request and ultimately a final determination, if needed, would be made by the Worker’s Compensation Board.

Data shows that most doctors are using between five and 15 types of drugs for worker’s comp from groups of anti-inflammatories, analgesics and muscle relaxers. It is expected that physicians will learn quickly what drugs are “Y” drugs on the formulary and will attempt to avoid the use of “N” drugs. The ODG formulary will be available on a web site portal of the Worker’s Compensation Board. Access to the portal will be free of charge and updated monthly.

Resource: Mike Ripley at (317) 264-6883 or email: [email protected]