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Good Morning
6:32:55 AM CDT
Tuesday, May 26, 2015

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Plan Design
The pharmacy plan design incorporates industry standards to ensure point-of sale processing of pharmacy charges for safe prescription use. Plan designs include:
  • Days Supply Limits:
    • 34 days for acute and 60 days for chronic medication
  • Medication Daily Dosage Limits:
    • Outlines the daily dosage limits for medications. Click here for a complete list.
  • Formulary/Medication Restrictions:
    • Medication excluded from coverage or requiring a Prior Authorization
    • Prior authorization can be requested in two ways:
      • Physician ordering the script can complete the P2 form
      • Pharmacist attempting to fill the script can call WSI at 1.800.777.5033 or 1.701.328.3800
    • Click here for a complete list of the medication restrictions
The following outlines the plan designs for dispensing generic medication 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
    • Injured workers requesting a brand medication are responsible to pay the cost difference from the generic medication
  • A “Brand Necessary” or DAW 1 prescription requires the prescriber to submit the prior authorization (P2) form with the supporting documentation substantiating the need for the brand product
    • Click here for the DAW 1 policy statement
    • If approved, it will be specific for the drug, dosage form, and strength
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