Plan Design

The pharmacy plan design incorporates industry standards to ensure point of sale processing of pharmacy charges.

Guidelines for safe prescription use:

  • Supply Limits – 34 days for acute and 60 days for chronic medication
  • Formulary/Medication Restrictions – lists medication excluded from coverage or requiring a prior authorization and medication quantity limits

Guidelines for dispensing generic vs. brand medication:

  • Generic medication prescribed for the work injury is covered
  • In the absence of a generic equivalent medication, a brand medication may be allowed
    • An injured worker may request a brand medication but is responsible to pay the cost difference between the generic and brand medication
  • Brand Necessary or DAW 1 prescriptions require the prescriber to submit the Physician’s Request for Medication Prior Authorization (M11)