Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.2. Medical Treatment Utilization Schedule

§ 9792.27.3. MTUS Drug Formulary Transition.

(a) Except as provided in subdivision (b), the MTUS Drug Formulary applies to drugs dispensed on or after January 1, 2018, regardless of the date of injury.

(b)(1) For injuries occurring prior to January 1, 2018, the MTUS Drug Formulary should be phased in to ensure that injured workers who are receiving ongoing drug treatment are not harmed by an abrupt change to the course of treatment. The physician is responsible for requesting a medically appropriate and safe course of treatment for the injured worker in accordance with the MTUS, which may include use of a Non-Exempt drug or unlisted drug, where that is necessary for the injured worker's condition or necessary for safe weaning, tapering, or transition to a different drug.

(2) If the injured worker with a date of injury prior to January 1, 2018 is receiving a course of treatment that includes a Non-Exempt drug, an unlisted drug, or a compounded drug, the physician shall submit a progress report issued pursuant to section 9785 and a Request for Authorization that shall address the injured worker's ongoing drug treatment plan. The report shall either:

(A) Include a treatment plan setting forth a medically appropriate weaning, tapering, or transitioning of the worker to a drug pursuant to the MTUS, or

(B) Provide supporting documentation, as appropriate, to substantiate the medical necessity of, and to obtain authorization for, the Non-Exempt drug, unlisted drug, or compounded drug, pursuant to the MTUS (via guidelines, Medical Evidence Search Sequence, and/or Methodology for Evaluating Medical Evidence.)

(3) The progress report, including the treatment plan and Request for Authorization provided under this subdivision, shall be submitted at the time the next progress report is due under section 9785, subdivision (f)(8), however, if that is not feasible, no later than April 1, 2018.

(4) Previously approved drug treatment shall not be terminated or denied except as may be allowed by the MTUS and in accordance with applicable utilization review and independent medical review regulations.

(5) The claims administrator shall process the progress report, treatment plan and Request for Authorization in accordance with the standard procedures and timeframes set forth in section 9792.6.1 et seq.

Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 4600, 4604.5 and 5307.27, Labor Code.

HISTORY

1. New section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2017, No. 49).