Prior Authorization for Brand Necessary Medications

Introduction

The purpose of this policy is to identify the circumstances under which Workforce Safety & Insurance (WSI) approves an authorization request for brand name medication in lieu of the generic equivalent.

Policy

WSI requires an injured employee complete a trial period using the generic equivalent medication prior to reviewing for authorization of the brand name medication. Upon completion of the trial period, a provider must complete the Provider’s Request for Medication Prior Authorization (M11) form to request prior authorization of a brand name medication in lieu of the generic equivalent. The request must include documentation demonstrating objective medical evidence of the following:

• An adverse reaction to the generic medication not present with the equivalent brand name product.
• Inadequate therapeutic response to the generic medication not present with the equivalent brand name product. The documentation must contain measurable, objective evidence to support the inadequate response to the generic equivalent of the requested brand name medication. 

An approval for a brand name medication is specific to the medication, strength, and dosage. The authorization will be valid for a maximum of one year. To renew the authorization of a brand name medication, a provider must submit the M11 on an annual basis.