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

§ 9792.27.13. MTUS Drug List - Perioperative Fill.

(a) The MTUS Drug List identifies drugs that are subject to the Perioperative Fill policy. Under this policy, the Non-Exempt drug identified as a Perioperative 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 during the perioperative period; 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 Perioperative 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.

(b) For purposes of this section, the perioperative period is defined as the period from 4 days prior to surgery to 4 days after surgery, with the day of surgery as “day zero”.

(c) An employer or insurer that has a contract with a pharmacy, pharmacy network, pharmacy benefit manager, or a medical provider network that includes a pharmacy or pharmacies within the MPN, may provide for a longer Perioperative Fill period or may cover additional drugs under the Perioperative Fill policy pursuant to a pharmacy benefit contract or MPN contract.

Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 4600, 4604.5 and 5307.27, Labor Code.

HISTORY

1. New section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2017, No. 49).