Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.1. Utilization Review Standards

§9792.9.8. Utilization Review -- MTUS Drug Formulary.

(a) This subdivision governs review of Exempt Drugs listed on the MTUS Drug List.

(1) Notwithstanding sections 9792.9.1 through 9792.9.7, the following drugs can be dispensed to an injured worker without obtaining authorization through prospective review:

(A) Drugs identified on the MTUS Drug List as exempt under section 9792.27.15;

(B) Drugs identified on the MTUS Drug List as subject to and when dispensed in accordance with the Special Fill policy under section 9792.27.12; and

(C) Drugs identified on the MTUS Drug List as subject to and when dispensed in accordance with the Perioperative Fill policy under section 9792.27.13.

(2) Exempt drugs identified in subsection (1) must still be set forth in a request for authorization as required under section 9792.6.1(u), or in a manner agreed upon by the treating physician and the claims administrator.

(b) This subdivision governs review of Non-Exempt Drugs that are listed on the MTUS Drug List. For a drug not covered under subdivision (a) of this section, regardless of whether a drug is prescribed and dispensed within 30 days from the date of injury, the treating physician must request authorization through prospective utilization review by submitting a request for authorization in the manner set forth in section 9792.6.1(u), or in a manner agreed upon by the treating physician and the claims administrator.

(1) Prospective decisions to approve, modify, or deny a request for authorization for a drug not covered under subdivision (a) of this section shall be made in a timely fashion that is appropriate for the nature of the injured worker's condition, not to exceed five (5) business days from the date of receipt of the request for treatment. The reviewer or non-physician reviewer may request the treating physician to provide additional information reasonably necessary to make a determination as follows:

(A) The reviewer or non-physician reviewer shall request the information from the treating physician within four (4) business days from the date of receipt of the request for authorization.

(B) If the information is not received within five (5) business days from the date of the request for authorization of treatment, a physician reviewer may deny the request in accordance with section 9792.9.5, subdivision (e).

(2) The decision shall be communicated in the manner set forth in sections 9792.9.4 and 9792.9.5.

(3) The extension of time as set forth in section 9792.9.6 is not applicable to a request for authorization of a drug covered under this subdivision.

(c) This subdivision governs review of drugs that are not listed on the MTUS Drug List. A treating physician must request authorization through prospective review for a drug not listed on the MTUS Drug List by submitting a request for authorization in the manner set forth in section 9792.6.1(u) or in a manner agreed upon by the treating physician and the claims administrator, regardless of whether a drug is prescribed or dispensed within 30 days from the date of injury. Prospective decisions to approve, modify, or deny a request for authorization of a drug not listed on the MTUS Drug List shall be made in a timely fashion in accordance with section 9792.9.3 and section 9792.9.6. The decision shall be communicated in the manner set forth in sections 9792.9.4 and 9792.9.5.

(d) Notwithstanding subdivision (b), a request for authorization that requests both drugs and non-pharmaceutical treatment related to the same injury or illness shall be reviewed under the timeframes set forth in section 9792.9.3 and section 9792.9.6 and the requirements of sections 9792.9.4 and 9792.9.5.

(e) Except for drugs that fall under 9792.9.7(a), a utilization review decision to deny a request for authorization of a drug which falls under subdivision (a) of this section based on the failure of the treating physician to prescribe or dispense the medication consistent with the recommendations set forth in the applicable guideline of the medical treatment utilization schedule, can be grounds for the denial of payment for the medication.

(f)(1) A decision to modify or deny a request for authorization under this section based on medical necessity shall be reviewed only through the claims administrator's voluntary internal utilization review appeals process, or the independent medical review provisions of Labor Code section 4610.5 and 4610.6.

(2) A dispute regarding a decision to modify or deny a request for authorization under this section based on a reason other than medical necessity shall be resolved either by agreement of the parties or through the dispute resolution process of the Workers' Compensation Appeals Board.

(3) If a decision is made to modify or deny a request for authorization under this section based on both medical necessity and a reason other than medical necessity, the non-medical necessity dispute shall be resolved first.

(g) The following rules apply when a treating physician prescribes or dispenses a drug to treat an injured worker under the provisions of section 9792.9.7(a).

(1) The injured worker's initial treating physician shall describe in the treatment plan on the "Doctor's First Report of Occupational Injury or Illness," DIR Form 5021, all drugs that are being prescribed or dispensed to treat the injured worker, and list on the request for authorization required under section 9792.9.7(a)(4), all drugs that are being prescribed or dispensed. Subsequent primary treating physicians shall submit a request for authorization following their first visit with the injured worker indicating all drugs that are being prescribed or dispensed for treatment.

(2) The treating physician may prescribe or dispense a drug identified under subdivision (a) of this section without the need to obtain authorization through prospective utilization review.

(3) For a drug not covered under subdivision (a) of this section, the treating physician must request authorization through prospective utilization review by submitting a request for authorization in the manner set forth in section 9792.9.1, or in a manner agreed upon by the treating physician and the claims administrator.

(4) The claims administrator may conduct retrospective review of a drug prescribed or dispensed to the injured worker under subdivision (a) of this section only for the purpose of determining whether the use of the drug is consistent with the recommendations set forth in the applicable guideline of the medical treatment utilization schedule adopted by the administrative director under Section 5307.27.

(A) Payment for an exempt drug dispensed under the provisions of section 9792.9.7(a) shall not be denied based on a determination that use of the drug was not consistent with the applicable guideline.

(B) Use of an exempt drug that is not consistent with the applicable guideline may be used as a basis to find that the physician, under section 9792.9.7(c), has a pattern and practice of failing to render treatment that is consistent with the Medical Treatment Utilization Schedule.

Credits

Note: Authority cited: Sections 133, 4610, 5307.3 and 5307.27, Labor Code. Reference: Sections 4600, 4600.4, 4604.5, 4610 and 5307.27, Labor Code.

History

1. New section filed 12-30-2025; operative 4-1-2026 (Register 2026, No. 1).