The Bureau of Workers’ Compensation has adopted the Work Loss Data Institute ODG® Drug Formulary (Appendix A) as the Drug Formulary for use in the Tennessee Workers’ Compensation system. This allows for the review of certain medication prescribed to patients under workers’ compensation. It identifies some medications within certain classes to require approval prior to dispensing. These medications are listed as a status “N” in the formulary.
Medication listed as status “Y” or medications not listed may be dispensed without prior approval but may be subject to later review under certain circumstances.
The carrier or authorized pharmacy benefits manager will continue to make these determinations. These later reviews would not affect the drugs already dispensed but may affect future refills. No change in the present processes for prescribing, dispensing and review will occur until the dates listed below.
* For first prescriptions written and dispensed for the affected medications after January 1, 2016, the drug formulary will apply after August 28, 2016.
* For refills of medications with prescriptions written before January 1, 2016, the drug formulary will apply after February 28, 2017.
These notification periods allows all parties to become familiar with the formulary before any change in the present process will occur. Drug Formulary Drug Formulary FAQ Further instructions are in the “Read Me” section of the Excel file.
Further instructions are in the “Read Me” section of the Excel file.
For urgent prescription denials, use this form to appeal a denied prescription to the Bureau's Medical Director.
A prescribing doctor or pharmacy can request an expedited determination (Appeal of a Denied Prescription) when a denial of a previously prescribed and the dispensed drug is received (that either is now not covered under the drug formulary or requires prior approval) and either:
- The lack of this medication poses an unreasonable risk of a medical emergency as defined in 0800-02-25.04; or
- The substitution of another drug cannot or should not be made for a valid medical reason.
Frequently Asked Questions about appealing a denied prescription fill
- A "REQUEST FOR EXPEDITED DETERMINATION-APPEAL OF A DENIED PRESCRIPTION" form should be completed by the prescribing doctor or pharmacist and submitted to the Bureau's Medical Director.
- Failure to complete the form prior to submitting it may result in the appeal being denied.
The appeal form must be submitted within fifteen (15) business days for an initial "Needs Prior Approval" denial. NOTE: You must submit your appeal of a "Reconsideration" denial within five (5) business days with the insurance carrier/adjuster, not with the Bureau. The form is not required for this appeal.
Upon the Medical Director's approval, the approval is effective retroactively to the date of the original prescription. The determination remains in effect until the later of:
- A final determination of a medical dispute regarding the medical necessity and reasonableness of the drug contained in the appeal;
- The expiration of the period for a timely appeal; or
- The agreement of the parties.
You can fax it to 615-253-5265; or
You can scan it and email it to firstname.lastname@example.org; or
You can mail it to:Tennessee Bureau of Workers' Compensation
ATTN: Medical Unit
220 French Landing Drive, 1-B
Nashville, Tennessee 37243
Workers' Compensation Rules are available on the Rules page of the Bureau's website.
- Look for Chapter 0800-02-.25 Workers' Compensation Medical Treatment Guidelines.
- Find rule 0800-02-25-.04 Drug Formulary within that Chapter.