Okla. Admin. Code § 810:15-5-3
Current through Vol. 42, No. 4, November 1, 2024
Section 810:15-5-3 - Requirements for use of closed formulary(a)Applicability. The closed formulary adopted pursuant to 810:15-5-2 applies to all drugs that are prescribed and dispensed for outpatient use for claims with a date of injury on or after February 1, 2014.(b)Preauthorization for claims subject to the Commission's closed formulary. Preauthorization is only required for drugs that are excluded from the closed formulary, as defined in this Chapter.(c)Preauthorization request. The preauthorization request must include the prescribing doctor's drug regimen plan of care, and the anticipated dosage or range of dosages for the drugs. Failure to request preauthorization entitles an insurance carrier or employer to deny payment for the drug in question. If the insurance carrier or employer fails to respond to a preauthorization request within three (3) days, the request shall be deemed approved.(d)Preauthorization of intrathecal drug delivery systems.(1) An intrathecal drug delivery system requires preauthorization and the preauthorization request must include the prescribing doctor's drug regimen plan of care, and the anticipated dosage or range of dosages for the administration of pain medication.(2) Refills of an intrathecal drug delivery system with drugs excluded from the closed formulary, which are billed using Healthcare Common Procedure Coding System (HCPCS) Level II J codes, require preauthorization on an annual basis. Preauthorization for these refills is also required whenever: (A) the medications, dosage or range of dosages, or the drug regime proposed by the prescribing doctor differs from the medications, dosage or range of dosages, or drug regime previously preauthorized by that prescribing doctor; or(B) there is a change in prescribing doctor.(e)Treatment guidelines. Except as provided by this Subsection, the prescribing of drugs shall be in accordance with 810:15-7-1 relating to treatment guidelines. Prescription and nonprescription drugs included in the Commission's closed formulary may be prescribed and dispensed without preauthorization.(f)Appeals process for drugs excluded from the closed formulary(1) For situations in which the prescribing doctor determines and documents that a drug excluded from the closed formulary is medically necessary to treat an injured employee's compensable injury and has prescribed the drug, the prescribing doctor, other requestor, or injured employee must request approval of the drug by requesting preauthorization from the insurance carrier, or pursuant to the preauthorization requirements of a certified workplace medical plan, if the claim is subject to the plan.(2) If preauthorization is requested by an injured employee or a requestor other than the prescribing doctor, and the injured employee or other requestor requests a statement of medical necessity, the prescribing doctor shall provide a statement of medical necessity as set forth in Subsection (e) of 810:15-5-1 to facilitate the preauthorization submission.(3) If preauthorization for a drug excluded from the closed formulary is denied, the requestor may request a hearing before an administrative law judge of the Commission by filing a CC-Form-9 as provided in 810:10-5-16.(4) In the event of an unreasonable risk of a medical emergency, an interlocutory order may be obtained in accordance with 810:15-5-4.Okla. Admin. Code § 810:15-5-3
Adopted by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015Amended by Oklahoma Register, Volume 33, Issue 24, September 1, 2016, eff. 9/12/2016