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The Division of Workers' Compensation (DWC) Will Need to Weigh the Benefits of Remaining Consistent with the Current MTUS Structure Against the Ease of Implementing the Formulary

• To remain consistent with the MTUS guidelines, DWC will need to either adopt existing the guidelines and formulary (the Work-Loss Data Institute's ODG or The Reed Group's ACOEM) or derive the formulary drug listing from MTUS guidelines.
• The existing sources have advantages and disadvantages. The ODG guidelines are more comprehensive and updated regularly. The formulary drug listing has prospective review (PR) requirements and could be implemented off the shelf. The MTUS guidelines for chronic pain are based on ODG, although most MTUS guidelines are based on ACOEM. The ACOEM guidelines have a more rigorous development process but are less comprehensive. Updates occur every three to five years. The drug recommendations are condition-specific, with no PR requirements. DWC would need to develop a formulary drug listing and PR requirements.
• The MTUS guidelines are outdated. An MTUS formulary would require updating the guidelines; developing a formulary drug list and PR requirements; and, if the current multisource structure is retained, integrating guidelines from different sources into a single formulary.
• The Labor Code's different administrative processes for updating the treatment guidelines and the formulary pose challenges for maintaining currency and consistency between the guidelines and formulary recommendations.

California Assembly Bill 1124 required the state's Division of Workers' Compensation in the Department of Industrial Relations to establish a drug formulary for all injured workers covered by the state's workers' compensation program. Such formularies serve to reinforce safe and effective prescribing patterns for practitioners and payers. In California, the formulary will need to be consistent with the Medical Treatment Utilization Schedule guidelines that define medically appropriate care for California's injured workers, create incentives to encourage prescribing of medically appropriate drugs, and reduce the administrative burdens associated with utilization review and medical necessity disputes. The objective of this report is to support the Division of Workers' Compensation in establishing the formulary. The authors compare and evaluate the strengths and weaknesses of four existing formularies and the formulary used by California's Medicaid program. The authors then analyze the issues involved in structuring the drug formulary for California to be consistent with the treatment guidelines, explore related policies that should be addressed in implementing the formulary, and offer recommendations.

• Chapter One

  Introduction

• Chapter Two

  An Overview of Outpatient Drugs Furnished to Injured Workers

• Chapter Three

  Comparison of Existing Drug Formularies

• Chapter Four

  Comparison of Formulary Ground Rules

• Chapter Five

  Formulary Implementation Policies

• Chapter Six

  Formulary Updating Process and Policies

• Chapter Seven

  Preliminary Implementation Plan

• Appendix A

  Detailed Methods and Results for Chapter Four

• Appendix B

  Example Formulary