Okla. Admin. Code § 810:15-5-1

Current through Vol. 41, No. 24, September 3, 2024

Section 810:15-5-1 - Pharmaceutical services

(a)Prescriptions. A doctor providing care to an injured employee shall prescribe for the employee medically necessary prescription drugs and over-the-counter medication alternatives as clinically appropriate and applicable in accordance with state law and as provided by this Section.

(b)OTC medications. When prescribing an OTC medication alternative to a prescription drug, the doctor shall indicate on the prescription the appropriate strength of the medication and the approximate quantity of the OTC medication that is reasonably required by the nature of the compensable injury. The doctor shall prescribe OTC medications in lieu of a prescription drug when clinically appropriate.

(c)Generic prescriptions. The doctor shall prescribe generic prescription drugs when available and clinically appropriate. If in the medical judgment of the prescribing doctor a brand name drug is necessary, the doctor must specify on the prescription that brand name drugs be dispensed in accordance with applicable state and federal law, and must maintain documentation justifying the use of the brand name drug, in the patient's medical record.

(d)Use of formulary. When prescribing, the doctor shall choose medications and drugs from the formulary adopted by the Commission.

(e)Statement of medical necessity. The insurance carrier, employee or pharmacist may request a statement of medical necessity from the prescribing doctor. The prescribing doctor shall provide the statement of medical necessity to the requesting party no later than the fourteenth working day after receipt of a request.

(f)Explanation of benefits. In addition to other requirements regarding explanation of benefits (EOB) provided in the Oklahoma workers' compensation fee schedule, at the time an insurance carrier denies payment for medications for any reason related to medical necessity or reasonableness of health care, the insurance carrier shall also send the EOB to the injured employee and the prescribing doctor.

(g)Billing and reimbursement. Billing, reimbursement methodologies and the maximum allowable reimbursement for pharmaceutical services are subject to 85A O.S., § 50 and the Oklahoma workers' compensation fee schedule in effect on the date of service, unless the services are provided pursuant to a certified workplace medical plan or a written contract between the insurance carrier and provider as provided in 85A O.S., § 55(B).

Okla. Admin. Code § 810:15-5-1

Adopted by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015