What general limitations are in place for drugs?
(1) Amount dispensed. The department or self-insurer will pay for no more than a thirty-day supply of a drug dispensed at any one time except in pension cases (see subsection (6) of this section) and claims that are held open for life-sustaining treatment. In these cases, up to a ninety-day supply of the drug is payable when:
• Coverage has been authorized; and
• The drug is not a controlled substance; and
• The drug is obtained through a designated provider.
(2) Over-the-counter drugs. Prescriptions for over-the-counter items may be paid. Special compounding fees for over-the-counter items are not payable.
(3) Generic drugs. Prescriptions are to be written for generic drugs unless the provider specifically indicates that substitution is not permitted. For example: The worker cannot tolerate substitution. Pharmacists are instructed to fill with generic drugs unless the provider specifically indicates substitution is not permitted.
(4) Evidence-based prescription drug program.
In accordance with RCW 70.14.050
, the department in cooperation with other state agencies may develop a preferred drug list. Any pharmacist filling a prescription under state purchased health care programs as defined in RCW 41.05.011
(2) shall substitute, where identified, a preferred drug for any nonpreferred drug in a given therapeutic class, unless the endorsing practitioner has indicated on the prescription that the nonpreferred drug must be dispensed as written, or the prescription is for a refill of an antipsychotic, antidepressant, chemotherapy, antiretroviral, or immunosuppressive drug (see RCW 69.41.190
), or for the refill of an immunomodulator/antiviral treatment for hepatitis C for which an established, fixed duration of therapy is prescribed for at least twenty-four weeks but no more than forty-eight weeks or the nonendorsing practitioner has received prior authorization from the department to fill the prescription as written, in which case the pharmacist shall dispense the prescribed nonpreferred drug.
(5) Prescriptions for unrelated medical conditions.
The department or self-insurer may consider temporary coverage of prescriptions for conditions not related to the industrial injury when such conditions are retarding recovery. Any treatment for such conditions must have prior authorization per WAC 296-20-055
. This would apply to any prescription for such conditions even when the endorsing practitioner indicates "dispense as written."
(6) Pension cases. When the worker is placed on a pension, the department or self-insurer may pay, at the sole discretion of the supervisor of industrial insurance, for only those drugs authorized for continued medical treatment of previously accepted conditions:
(a) Coverage must be authorized before the treatment is rendered.
(b) Controlled substances used to treat continuing pain resulting from an industrial injury or occupational disease are not payable.
[Statutory Authority: RCW 51.04.020
. WSR 13-12-024, § 296-20-03011, filed 5/28/13, effective 7/1/13; WSR 07-17-167, § 296-20-03011, filed 8/22/07, effective 9/22/07. Statutory Authority: RCW 51.04.020
. WSR 04-08-040, § 296-20-03011, filed 3/30/04, effective 5/1/04. Statutory Authority: RCW 51.04.020
. WSR 00-01-040, § 296-20-03011, filed 12/7/99, effective 1/20/00.]