Nonformulary Misstep: ECAB Upholds Denial of Brand-Name Pain Patch

Federal Focus

A postal worker’s failure to submit medical evidence justifying the need for a nonformulary, name‑brand medication led ECAB to affirm OWCP’s denial of authorization. Simply Research subscribers have access to the full text of the decision.

Case

D.F. and U.S. Postal Service, No. 23-1159 (ECAB 03/05/26)

What Happened?

A mail processor filed a traumatic injury claim, alleging that she injured her right hand and shoulder while sweeping and sorting mail in the performance of duty. The Office of Workers' Compensation Programs accepted the claim and paid the processor wage-loss compensation on the supplemental rolls and then the periodic rolls.

Later, the processor's doctor renewed the processor's prescription for Butrans patches, noting that she required the name-brand because the generic patch did not stick to her skin effectively, resulting in inconsistent medication delivery.

OWCP's pharmacy benefit manager advised the processor that pharmacy benefits for injured employees under the Federal Employees Compensation Act were managed under a drug formulary, and that the prescription for Butrans was outside the formulary allowances.

Ultimately, OWCP denied authorization for Butrans, finding that the evidence of record was insufficient to establish that the medication was medically necessary to address the effects of her accepted condition under FECA.

The processor sought review from the Employees' Compensation Appeals Board.

Rule of Law

Under FECA, federal employees who are injured while in the performance of duty must receive the services, appliances, and supplies prescribed or recommended by a qualified physician. ECAB has recognized that OWCP has broad discretion in approving services provided, with the only limitation on OWCP's authority being that of reasonableness.

What ECAB Said

ECAB found that OWCP properly denied authorization for a nonformulary prescription medication.

Specifically, the PBM advised the processor's physician that the prescription was outside the formulary allowances, and it advised him to take one of the following actions:

(1) Transition the processor's prescription to comply with the formulary allowances.

(2) Transition the processor to a different formulary medication, complying with the formulary allowances.

(3) Request a prior authorization via the prescriber portal to obtain approval or an exception to the formulary allowance.

As neither the claimant nor her physician pursued prior authorization or provided a rationalized medical explanation establishing the necessity of the nonformulary medication over available formulary alternatives, ECAB found that OWCP properly denied authorization.

Verdict: ECAB affirmed OWCP's decision.

Takeaway

Claimants seeking nonformulary medications under FECA must submit a well-rationalized medical opinion explaining why formulary alternatives are inadequate and should ensure that prior authorization procedures are properly pursued.

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