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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.2. Medical Treatment Utilization Schedule

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§ 9792.27.12. MTUS Drug List - Special Fill.

(a) The MTUS Drug List identifies drugs that are subject to the Special Fill policy. Under this policy, a drug that usually requires prospective review because it is “Non-Exempt” will be allowed without prospective review as specified in subdivision (b).
(b) The drug identified as a Special Fill drug may be dispensed to the injured worker without seeking prospective review if all of the following conditions are met:
(1) The drug is prescribed at the single initial treatment visit following a workplace injury, provided that the initial visit is within 7 days of the date of injury; and
(2) The prescription is for a supply of the drug not to exceed the limit set forth in the MTUS Drug List; and
(3) The prescription for the Special Fill-eligible drug is for:
(A) An FDA-approved generic drug or single source brand name drug, or,
(B) A brand name drug where the physician documents and substantiates the medical need for the brand name drug rather than the FDA-approved generic drug, and
(4) The drug is prescribed in accordance with the MTUS Treatment Guidelines.
(c) When calculating the 7-day period in subdivision (b)(1), the day after the date of injury is “day one.”
(d) An employer or insurer that has a contract with a pharmacy, pharmacy network, pharmacy benefit manager, or a medical provider network (MPN) that includes a pharmacy or pharmacies within the MPN, may provide for a longer Special Fill period or may cover additional drugs under the Special Fill policy pursuant to a pharmacy benefit contract or MPN contract.
(e) After the Special Fill provision has been in effect for one year, the Administrative Director shall evaluate the impact of the provision on the use of opioids by injured workers. As part of the evaluation process, the Administrative Director shall solicit feedback from the workers' compensation system participants.
Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 4600, 4604.5 and 5307.27, Labor Code.
1. New section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2017, No. 49).

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