Which drugs have specific limitations?
(1) Injectables. Prescriptions for injectable opioids or other analgesics, sedatives, antihistamines, tranquilizers, psychotropics, vitamins, minerals, food supplements, and hormones are not covered.
Exceptions: The department or self-insurer covers injectable medications under the following circumstances.
(a) Indicated injectable drugs for the following:
• Inpatients; or
• During emergency treatment of a life-threatening condition/injury; or
• During outpatient treatment of severe soft tissue injuries, burns or fractures when needed for dressing or cast changes; or
• During the perioperative period and the postoperative period, not to exceed forty-eight hours from the time of discharge.
(b) Prescriptions of injectable insulin, heparin, anti-migraine medications, or impotency treatment, when proper and necessary.
(2) Noninjectable scheduled drugs administered by other than the oral route. Nonoral routes of administration of scheduled drugs that result in systemic availability of the drug equivalent to injectable routes will also not be covered.
(3) Sedative-hypnotics. During the chronic stage of an industrial injury or occupational disease, payment for scheduled sedatives and hypnotics will not be authorized.
(4) Benzodiazepines. Payment for prescriptions for benzodiazepines are limited to the following types of patients:
• Hospitalized patients;
• Claimants with an accepted psychiatric disorder for which benzodiazepines are indicated;
• Claimants with an unrelated psychiatric disorder that is retarding recovery but which the department or self-insurer has temporarily authorized treatment (see WAC 296-20-055
) and for which benzodiazepines are indicated; and
• Other outpatients for not more than thirty days for the life of the claim.
(5) Cancer. When cancer or any other end-stage disease is an accepted condition, the department or self-insurer may authorize payment for any indicated scheduled drug and by any indicated route of administration.
(6) Spinal cord injuries. When a spinal cord injury is an accepted condition, the department or self-insurer may authorize payment for anti-spasticity medications by any indicated route of administration (e.g., some benzodiazepines, Baclofen). Prior authorization is required.
Note: See the department formulary for specific limitations and prior authorization requirements of other drugs.
[Statutory Authority: RCW 51.04.020
and 51.04.030. WSR 00-01-040, § 296-20-03014, filed 12/7/99, effective 1/20/00.]