Texas: Potential Enforcement Action

Texas: Potential Enforcement Action

The Division is reminding system participants that enforcement actions may be taken against stakeholders who perform any activity in violation of the statutes or rules. Recent reminders include:

A. New EDI Forms

The Division created new EDI forms including the EDI-01, EDI-02, and EDI-03. Carriers must ensure that the proper forms are filed with the Division. New Austin Representative forms must be completed and signed by the insurance carrier. The Division is warning carriers they may initiate enforcement action if the EDI-03 is not completed.

B. Prescription Drugs

The Division is also warning carriers and pharmacy benefit managers (PBMs) that pre-authorization is not required for N-class drugs on legacy claims. Additionally, drugs dispensed on or after September 1, 2011 that exceed the ODG Guidelines do not require pre-authorization. Further, the Division suggests that a PBM’s use of proprietary formularies for legacy claims could trigger enforcement action. Thus, all carriers should ensure their PBMs are not using their proprietary formularies for legacy claims.

C. Legacy Claim’s Approaching Deadlines

No later than March 1, 2013, carriers must contact physicians who prescribed N-class drugs to injured workers after September 1, 2012. DWC urges carriers to contact these doctors as soon as possible. Perhaps, many of these doctors will agree the N-class drugs no longer represent the best medical care for injured workers. Carriers should have a plan in place to transition legacy claims to the closed drug formulary. The Division has drafted a discussion paper entitled “Elements of an Insurance Carrier Legacy Claim Program” and suggests that this serve as a starting point to establish an internal process transitioning legacy claims to the closed formulary on September 1, 2013.