Pharmacy Benefit Management
To maintain a cost effective approach for medications, WSI reimburses for
generic medications prescribed for the work injury. If an injured worker
is requesting a brand medication when an equivalent generic is available,
the injured worker will be required to pay the cost difference for the brand
medication. In the absence of a generic equivalent medication, a brand
medication would be covered by WSI.
WSI has a prior authorization procedure for prescriptions being written
with the “Brand Necessary” or DAW 1 orders. When the prescriber is
indicating a medication to be filled as “Brand Necessary,” WSI requires
the prescriber provide documentation to substantiate the need for the brand
product versus the equivalent generic.
Some additional points concerning dispensing branded medications:
- If the DAW1 requires prior authorization, the following message will
be sent from US Script: “DAW 1 Requires Prior Auth. Call WSI @ 1-800-777-5033.”
Another option is to call the WSI pharmacy director directly at 701-328-7222
- WSI contacts the prescriber and requests written documentation substantiating
the need for the brand product versus the generic equivalent
- WSI contacts US Script with an approval or denial
- WSI and/or US Script contacts the pharmacy with an approval or denial
- If the request is denied, the injured worker has the option of paying the cost difference between the generic and brand product
- Prior authorization will be specific for the drug, dosage form, and strength
|
