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Ca Drug Formulary
#1
Hi Folks

Anyone know where to find the new CA Drug Formulary ?

Thanks 

Shadow
 
Reply
#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
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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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.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#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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#9
I have been disabled from a cervical spine injury since 01-06-2003. I am 67 years old. Claim was filed in the State of Arizona. I initially had a fusion surgery done in 2003. I never worked again. I lived with my family in Illinois as I was lucky to be included in a family trust. I began receiving checks for a meial amount in 2005.

In 2009 my neck was causing me so much pain I traveled back to see my neurosurgeon in Mesa, AZ. After testing he informed me that the fusion hardware had come apart at some point in time. I had two errant screws which were roaming around in my neck. One was impinging on my spinal canal. He

At that time I was on no pain medicine. He sent me to a pain management facility in Mesa where I was treated for about three years. They started giving me oxycodone and oxycontin. They continued to raise the dose over time to find the level of medication that was sufficient to treat my pain. I had epidurals and nerve burnings. The therapy was marginally successful. I moved back to Arizona in 2014. I returned to my original attorney for advice as I was paying all my medical on my neck
out of pocket.

We filed a motion to reopen my case with the Industrial Commission. Between 2014 and 2018 I got progressively worse.
My neurosurgeon ,of renown in his field, testified that the old hardware should be removed and the fusion extended. Finally, in July 2018, the Industrial Commission ruled in my favor and I was provided an award granted medical, surgical and hospital benefits going back to 2017 until such time as my condition was deemed "stable." I had been on permanent disability but that was changed to "temporary partial disability." In January of 2019
my neurosurgeon retired, His practice was taken over by another neurosurgeon. He examined me and told me the new harware, installed in July of 18 was coming apart. There were two screws broken and backing-out into my esophagus. Plus the C-7 vertabrae was cracked. He recommended immediate surgery
and intends to take out the old hardware and replace it with locking screws. Huh... o.k.

In this transitional period as I am preparing for my third fusion
my feet have hurt me so bad that I can't hardly walk on them but a few hours a day. My neck hurts so bad that even with my medication I can't hardly stand the pain. I have been on virually the same pain medicine for nine years. That is 20mg. of oxycodone every six hours. Plus, 40mg. of oxycontin every 12 hours.
The Insurance Carrier paid me for one year of my past prescription bills which was about $2,700.00. They sent me a "tymsys" card to use to get my medicine from the pharmacy.

Finally-- here is my current problem!! My two prescriptions still require a verbal authorization from my adjuster. It usually takes
two - three days. No matter how hard the pharmacy and my doctor try to get my medication in a more timely manner, they can't seem to reach a method which will prevent me from running out for two to three days. After being on this level of medication
for nine years to go without is not much fun.

What can I do to make this system a bit more responsive, anything?

My next surgery is October 16th if everything is in order for the doctor to proceed.

Thank you,
Kellie
 
Reply
#10
(09-29-2019, 05:18 PM)Kellie Wrote: I have been disabled from a cervical spine injury since 01-06-2003. I am 67 years old. Claim was filed in the State of Arizona. I initially had a fusion surgery done in 2003. I never worked again. I lived with my family in Illinois as I was lucky to be included in a family trust. I began receiving checks for a meial amount in 2005.

In 2009 my neck was causing me so much pain I traveled back to see my neurosurgeon in Mesa, AZ. After testing he informed me that the fusion hardware had come apart at some point in time. I had two errant screws which were roaming around in my neck. One was impinging on my spinal canal. He

At that time I was on no pain medicine. He sent me to a pain management facility in Mesa where I was treated for about three years. They started giving me oxycodone and oxycontin. They continued to raise the dose over time to find the level of medication that was sufficient to treat my pain. I had epidurals and nerve burnings. The therapy was marginally successful. I moved back to Arizona in 2014. I returned to my original attorney for advice as I was paying all my medical on my neck
out of pocket.

We filed a motion to reopen my case with the Industrial Commission. Between 2014 and 2018 I got progressively worse.
My neurosurgeon ,of renown in his field, testified that the old hardware should be removed and the fusion extended. Finally, in July 2018, the Industrial Commission ruled in my favor and I was provided an award granted medical, surgical and hospital benefits going back to 2017 until such time as my condition was deemed "stable." I had been on permanent disability but that was changed to "temporary partial disability." In January of 2019
my neurosurgeon retired, His practice was taken over by another neurosurgeon. He examined me and told me the new harware, installed in July of 18 was coming apart. There were two screws broken and backing-out into my esophagus. Plus the C-7 vertabrae was cracked. He recommended immediate surgery
and intends to take out the old hardware and replace it with locking screws. Huh... o.k.

In this transitional period as I am preparing for my third fusion
my feet have hurt me so bad that I can't hardly walk on them but a few hours a day. My neck hurts so bad that even with my medication I can't hardly stand the pain. I have been on virually the same pain medicine for nine years. That is 20mg. of oxycodone every six hours. Plus, 40mg. of oxycontin every 12 hours.
The Insurance Carrier paid me for one year of my past prescription bills which was about $2,700.00. They sent me a "tymsys" card to use to get my medicine from the pharmacy.

Finally-- here is my current problem!! My two prescriptions still require a verbal authorization from my adjuster. It usually takes
two - three days. No matter how hard the pharmacy and my doctor try to get my medication in a more timely manner, they can't seem to reach a method which will prevent me from running out for two to three days. After being on this level of medication
for nine years to go without is not much fun.



What can I do to make this system a bit more responsive, anything?

My next surgery is October 16th if everything is in order for the doctor to proceed.

Thank you,
Kellie

Ask to be put on mail order service. large pharmacy services are automated and may avoid delays. You could try cutting back a few days every mnth until you have a backup supply.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
  


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