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Ca Drug Formulary
#1
Hi Folks

Anyone know where to find the new CA Drug Formulary ?

Thanks 

Shadow
 
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#2
https://www.dir.ca.gov/dwc/DWCPropRegs/M...g-List.pdf

This is proposed drug formulary, but it is subject to change before the final drug formulary comes out.
 
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#3
The effective date has been changed to Jan 1, 2018.
There is a more recent proposal
http://www.dir.ca.gov/dwc/DWCPropRegs/MT...mulary.htm
Signature/Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information.........
 
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#4
(11-30-2017, 08:17 PM)1171 Wrote: The effective date has been changed to Jan 1, 2018.
There is a more recent proposal
http://www.dir.ca.gov/dwc/DWCPropRegs/MT...mulary.htm

Thanks .. I am looking for what drugs Injured workers could pick from after the new year? 

Hopefully this could stop some of this long UR /IMR madness.


Shadow
 
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#5
It's a short list:
They,ll allow either one aspirin
Or 2 aspirin....
But not at the same time.
Signature/Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information.........
 
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#6
(12-01-2017, 05:52 AM)Shadow Wrote:
(11-30-2017, 08:17 PM)1171 Wrote: The effective date has been changed to Jan 1, 2018.
There is a more recent proposal
http://www.dir.ca.gov/dwc/DWCPropRegs/MT...mulary.htm

Thanks .. I am looking for what drugs Injured workers could pick from after the new year? 

Hopefully this could stop some of this long UR /IMR madness.


Shadow

Don't let these guidelines stop treatment. Often times a patients condition is complex and does not fall under MTUS.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#7
My condition is Complex . I just want to be free of pain and smile.

I often think why cant injured workers elect for Euthanasia.. why suffer like this .They wont treat us, and either will secondary insurance .At least my secondary will not touch a comp claim .
 
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#8
(12-04-2017, 05:25 AM)Shadow Wrote: My condition is Complex . I just want to be free of pain and smile.

I often think why cant injured workers elect for Euthanasia.. why suffer like this .They wont treat us, and either will secondary insurance .At least my secondary will not touch a comp claim .

I recommend going to your secondary insurance treater and get treatment through then if you have a denial from work comp. I believe it is illegal for them not to treat you under the affordable care act. You can call your private insurance and talk to a supervisor about denied treatment to make sure.

If your condition is complex and chronic it may not fall under MTUS. I use other treatment guidelines ALL the time and get authorizations. You have to be able to find appropriate guidelines that fit your condition and know how to incorporate it in a request and/or appeal. Also, when you get a denial look up the entire guideline they use as a means to deny and see if it even fits your condition. You may be surprised at the things I have found researching the BS UR provides. I will list some of the things I have found.

1. Medical treatment guideline used as a means to deny actually approved the request but UR reviewer took part of the guideline or part of a sentence in a guideline to give the impression it was denied.

2. Guideline used did not fit the patients condition and/or minimized the patients condition: For example I recently read a denial for opioids for back strain. The UR reviewer wrote the patient had a laminectomy and had back strain. This was not accurate as the report sent to UR clearly stated the IW fell from a roof, fractured several vertebrae, had a 360 3 level fusion that failed to fuse, had loosened hardware, cauda equine syndrome (loss of bladder control) and used a walker. How is this patient listed on the UR denial as having a discectomy (minor surgery which resulted in back strain?The UR reviewer used treatment guidelines for post laminectomy as a means to deny, which is a minor surgery compared to a 360 3 level fusion. I actually see this often where UR minimizes the patients condition as a means to deny treatment. This poor patient had a fusion that failed to fuse, unstable back with loosening of hardware. They denied his Vicodin. I was absolutely livid. 

3. UR denies based upon lack of information. This is the most common reason for denial. For example UR may deny stating patient has not attempted PT and conservative treatment first for a 10 year old claim (really, like this patient was not sent to PT in 10 years lol). This is when you or your doctor needs to file an internal UR appeal with the UR company and provide the missing records.

4. UR denies based upon guidelines for one body part, when the injured workers injuries are complex and multiple body parts are affected.

5. UR denial stating MTUS is silent on the request. Just because a request or condition is not in the MTUS guidelines, that cannot be used as a means to deny.

What can a California injured worker do when this happens? You can and should request an IMR however I have found many, if not most IMR reviewers just regurgitate the original denial and do not read the records I send in but they do list them. Yu should not just sent in the IMR form and not follow up and send records with a narrative addressing the things used to deny on the original request, otherwise you will just be denied again. Mist applicant attorney firms are just sending in the IMR request and when they receive the form from MAXIMUS where they can send records etc they rely on the claims adjuster to send 6 months of records. Who is addressing the reasons for the denial and/or sending in appropriate treatment guidelines as a means to approve? No one. If you are represented by an attorney YOU can still take over this by blacking out attorney info on the form and alert your attorney YOU want to handle IMR. After you send in the form in a few weeks MAXIMUS will send a form where YOU can send records. Your adjuster will usually only send the last 6 months of records and they may not address the reason of the denial. You can also send a narrative addressing the reasons for denial and appropriate treatment guidelines that better fit your condition. You can ask your doctor for help. Even if you do this I have seen MAXIMUS basically ignore records sent.

The BEST way to get treatment approved in my opinion is to look up appropriate guidelines and submit with the original request OR request an internal UR review after UR denies it. Many doctors are not aware you can do this but you have a much better chance getting approval this way. Look and read the last few pages of your UR denial and it will state where to send the UR appeal. There is a short window for internal UR appeals, 5-10 days from the day you receive the denial, depended upon the company. You or your doctor can write a narrative and address the reasons for the denial, submit treatment guidelines, and relevant medical records.

Where can you find treatment guidelines? You can find MTUS and chronic pain guidelines on the states webpage. ODG and ACOEM 2nd edition I have found on the internet but they charge for subscription, but I have found other ways around it. I have used Medicare guidelines, Aetna guidelines, Blue Shield, peer review and studies. Yes this is a complete PITA (pain in the a$$).

If anyone needs assistance with this let me know. I always offer my help with treatment denials but rarely does anyone take it. I can say I get most of my doctors requests approved using my system above.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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