Some members of the committee advising the California Division of Workers’ Compensation on its prescription drug formulary would like to fast-track certain topical analgesics by exempting them from utilization review.
Doing so, however, will require more analysis of the different prices for similar products and how to protect against bad actors who might game the system by prescribing the most expensive formulations, according to a discussion during the Pharmacy and Therapeutics Committee meeting Wednesday.
The P&T Committee advises the division on evidence-based changes to the formulary drug list, which identifies medications that are exempt from prospective utilization review when prescribed in accordance with the Medical Treatment Utilization Schedule. Medications designated as “non-exempt,” as well as those not listed in the formulary, require prior authorization. Compounded drugs require prior authorization under the DWC’s rules. Physician-dispensed drugs must also go through utilization review unless they are dispensed under the “special fill” or “perioperative fill” exemptions.
Kevin Tribout, executive director of public policy and regulatory affairs for Optum Workers’ Comp and Auto No-Fault, said during a public comment portion of the meeting that the problem with expensive topicals bypassing the system is not unique to California. He said there are basically two options to prevent bad actors from exploiting the price differences for similar drugs.
“It’s either going to be a requirement for prior authorization or it’s going to require a fee schedule cap,” he said. “That’s the only way you’re going to put a control on this and get the elements out there that are abusing it to stop.”
Committee member Dr. Basil Besh said the bad actors who “are ruining it for everybody” by choosing to carry and dispense what amounts to a $400 tube of Bengay are the worst-kept secret in the industry. And he said adding price controls to the formulary sounds to him like an issue for the state Legislature.
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