W. Va. Code R. § 85-20-54

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 85-20-54 - Drugs with Specific Limitations

54.1. Injectables. Prescriptions for injectable opioids or other analgesics, sedatives, antihistamines, tranquilizers, psychotropics, vitamins, minerals, food supplements, and hormones are not covered.

54.2. Exceptions: The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, covers injectable medications under the following circumstances.

a. Indicated injectable drugs for the following:

1. Inpatients; or

2. During emergency treatment of a life-threatening condition/injury; or

3. During outpatient treatment of severe soft tissue injuries, burns or fractures when needed for dressing or cast changes; or

4. During the perioperative period and the postoperative period, not to exceed forty-eight hours from the time of discharge.

b. Prescriptions of injectable insulin, heparin and related anticoagulants, anti-migraine medications, or impotency treatment, when proper and necessary.

54.3. Noninjectable scheduled drugs administered by other than the oral route. Nonoral routes of administration of scheduled drugs that result in systemic availability of the drug equivalent to injectable routes will also not be covered.

54.4. Sedative-hypnotics. During the chronic stage of an industrial injury or occupational disease, payment for scheduled sedatives and hypnotics will not be authorized.

54.5. Benzodiazepines. Payment for prescriptions for benzodiazepines is limited to the following types of patients:

a. Hospitalized patients;

b. Injured workers with an accepted psychiatric disorder for which benzodiazepines are indicated;

c. Injured workers with an unrelated psychiatric disorder that is retarding recovery but which the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, has temporarily authorized treatment and for which benzodiazepines are indicated; and d. Other outpatients for not more than thirty days for the life of the claim.

54.6. Cancer. When cancer or any other end-stage disease is an accepted compensable condition, the department or self-insurer may authorize payment for any indicated scheduled drug and by any indicated route of administration.

54.7. Spinal cord injuries. When a spinal cord injury is an accepted condition, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may authorize payment for anti-spasticity medications by any indicated route of administration (e.g., some benzodiazepines, Baclofen). Prior authorization is required.

W. Va. Code R. § 85-20-54