Workers' compensation bureau says outpatient medication formulary reflects pharmacy committee changes; lawmakers press on mental‑health coverage

Bureau of Workers' Compensation officials told the Joint Committee on Agency Rule Review that the bureau is rescinding an existing outpatient medication formulary appendix and enacting a revised appendix that reflects recommendations from its Pharmacy and Therapeutics committee.

The change was described during committee discussion of “Bureau Workers' Compensation 4120 three‑six‑twenty one‑three,” identified in the meeting as the outpatient medication formulary rule. Representative Brenner asked whether the update could leave injured workers without previously covered prescriptions.

Pete Mahali, director of enterprise legal services at the bureau, said the formulary process dates to the bureau’s initial review in February 2011 and that the Pharmacy and Therapeutics committee advises the bureau about which drugs and any restrictions should be placed on coverage. “We started out back in 02/2011 by looking at every drug we had paid for in the last 3 years,” Mahali said, describing how the committee and the bureau have narrowed the list over time.

Mahali said the bureau rescinds the older appendix and adopts a new one each time the rule is updated; the new appendix “is the old appendix with the changes that we've told everybody we were making.” He said the bureau aims to update the formulary twice a year because the formal rulemaking process takes time.

Freddie Johnson, who identified himself as “the chief medical service and appliance officer,” said the bureau’s pharmacy director is responsible for the specific changes and that the staff relies on the committee’s recommendations. On communications, Mahali said the bureau notifies injured workers for whom it had paid for a prescription when coverage will end: “we send letters to each of the injured workers that we have paid for that prescription for.” He added the bureau may also copy prescribing providers.

Lawmakers pressed the bureau on mental‑health coverage. Representative Brenner cited examples — a bank teller held at gunpoint, a first responder who witnessed a child burned, and a teenage employee who experienced sexual harassment — and asked whether employees with a mental‑health injury but no accompanying physical injury would be eligible for benefits.

A bureau official replied that, under current practice described at the meeting, an accompanying physical injury is required for an allowance on those types of mental‑health claims: without a physical injury “we would not be able to see those allowance in the claim.” The bureau also said that, if a clinically appropriate medication is not on the formulary, staff can consider payment based on medical documentation submitted by a treating physician.

Committee members and staff noted that the formulary changes and any drugs added or removed are described in the rule summary and the business impact analysis filed with the Common Sense Initiative Office.

No formal vote on the formulary rule occurred during the session; the discussion consisted of committee questions and staff responses. The bureau staff said they would provide additional confirmations about whether providers receive the same notices given to injured workers.

The committee did not adopt or reject the rule at this meeting; staff described the content and process for the update and answered lawmakers' questions about implementation and notification.