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Prescription medications are a large part of many Workers’ Compensation cases. With thousands of drugs on the market, many being actively promoted to doctors by the pharmaceutical companies that hold the patent on them, how does a doctor determine which is the best drug to prescribe? Every year, the US Food and Drug administration approves large numbers of new drugs, the majority of which are essentially the same as a previously approved drug, but which have been reformulated, often in a minor way, as patents expire on older versions and generics containing the same active ingredient become available. Furthermore, new information often becomes available concerning potential problems with both brand name drugs and their generic version. These are sometimes in the form of interactions with other drugs or serious side effects; but the biggest pharmaceutical drug problem facing the nation today is the rising tide of opioid addiction.
California Law AB 1124, passed in 2015 and scheduled to be fully implemented by July of 2017, is an attempt by state lawmakers to create a formulary—a list of prescription medications that are proven to be effective treatments for conditions suffered by injured workers that is based on solid medical evidence that are also cost effective. The most important considerations behind passing this law are the toll that over prescribed opioid drugs are taking on the injured, the rising cost of all types of prescription medications, and ensuring that injured workers get the most effective treatment to get them back on the job as soon as possible.
AB 1124 is intended to prevent unnecessary prescription of potentially addictive drugs and to ensure that injured workers have access to evidence-based medical treatment by creating a formulary that is regularly reviewed and updated to include new treatments and exclude those found to be dangerous or ineffective, while providing timely benefits to claimants with minimal need for them to turn to the dispute process. Doctors treating Workers’ Compensation patients will be required to choose treatments that have been scientifically proven beneficial for the injury or disease for which they are being prescribed by consulting state guidelines set forth in the Medical Treatment Utilization Schedule (MTUS), which will include information on the effectiveness, dosing, frequency, and duration of use, along with other pertinent information.
The California formulary to be employed in state Workers’ Compensation cases under AB 1124 is based on other well-established evidence-based formularies from the American College of Occupational and Environmental Medicine (ACOEM) Washington Department of Labor and Industry, Official Disability Guidelines (ODG), and California Department of Healthcare Services (MediCal).
The formulary will simplify the prescribing of medications and treatments and offer protections against prescribing errors and overprescribing of certain drugs, such as opioid pain killers, benzodiazepines, and certain muscle-relaxers with the potential to be habit forming and while ensuring that new treatments and the latest medical knowledge are reflected in the guidelines. This does not mean that the drugs excluded from the formulary will be out of reach for patients for whom alternative drugs are not effective, but they will need a pre-authorization before these prescriptions can be filled. The formulary will also prevent the prescribing of unnecessarily high-priced patented pharmaceuticals when there is no evidence that they are superior to a less expensive generic version.
The new system should reduce the necessity for disputes between a claimant and the insurer over the appropriateness of a particular treatment their doctor is recommending. The law requires a quarterly updating of the formulary; but as with any bureaucratically administered program, there will be certain —but hopefully limited—situations in which the formulary may lag behind the current state of medical knowledge. And there could be delays in the approval process, which could potentially prevent some patients in need from getting immediate access to an excluded drug.
All in all, a well-designed formulary system should improve the quality of medical care to injured workers. But there will continue to be situations in which disputes arise, especially in the early phases of the program.