JCAR members press BWC on outpatient drug formulary changes and mental‑health coverage

The Joint Committee on Agency Rule Review questioned Bureau of Workers' Compensation officials about changes to the agency's outpatient prescription drug formulary and what those changes mean for injured workers' access to medications.

Representative Brenner asked whether workers who previously had prescriptions covered under the rescinded appendix could lose coverage under the new appendix. “So I guess what my concern is, are there any workers out there that might whose prescriptions may have been covered before under the old appendix but now could potentially lose their prescription drug coverage?” he asked.

Freddie Johnson, identified in the meeting as the bureau's chief medical service and appliance officer, said the bureau's pharmacy director leads formulary changes and that the agency's pharmacy and therapeutics committee recommends additions or removals. Pete Mahaley, director of enterprise legal services at the bureau, told the committee the formulary rule has existed since February 2011 and that the bureau updates the appendix when the committee recommends changes: “the formulary we've had a formulary in place, this rule, since, February, and and we have a pharmacy and therapeutics committee.”

Mahaley said the bureau rescinds the old appendix and enacts a new one to reflect committee recommendations and that the business impact analysis and rule summary spell out what changed. He added the bureau plans to update the formulary twice a year to match committee recommendations and the time required for rulemaking.

Mahaley also said the bureau attempts to avoid removing a sole available treatment for a covered condition: “we're not gonna take the only drug available to treat this injured workers allowed condition off the formulary.” He said the bureau notifies injured workers who have received a drug that will no longer be paid for and may copy providers: “we send letters to the injured workers saying, hey. As of such and such date, this drug's no longer gonna be paid for. Talk to your, talk to your doctor about, you know, other drugs that are available that that are on our formulary.”

Representative Brenner and other members pressed about mental‑health medications. Brenner noted several on the rescinded and new lists appeared to be mental‑health drugs and asked whether employees who suffer mental injuries without an accompanying physical injury—such as first responders or victims of workplace assault—would be eligible for BWC benefits. Bureau staff responded that, under current practice discussed in the meeting, an accompanying physical injury is required for allowance of those claims. One official said: “at this point, I would say without that accompanying physical injury, we would not be able to see those allowance in the claim.”

Committee members also asked whether providers would be notified when drugs are removed; staff agreed to confirm provider notification after the meeting. Officials said there are administrative paths to pay for services or drugs not listed on the formulary if medical documentation and review show the item is appropriate.

The committee's discussion did not result in a change or formal vote on the rule during the meeting; members asked for follow‑up confirmations on provider notices and details about the timing of notifications.