Exempt Drugs and Utilization Review

The latest argument being advanced by the applicant community is that “exempt” medications are not subjected to Utilization Review. We disagree.

The Medical Treatment Utilization Schedule (MTUS) is defined by 8 CCR 9792.27.1. Subsection (h) provides that “”Exempt drug means a drug on the MTUS Drug List which is designated as being a drug that does not require authorization through prospective review prior to dispensing the drug, provided that the drug is prescribed in accordance with the MTUS Treatment Guidelines”. (Underlining added by this writer).

If one is to follow the argument that exempt medications are not subject to review, the adjuster is then required to make a determination on their own if the prescribed medication is “in accordance with the MTUS Treatment Guidelines.” Such a position requires a non-physician to make a medical determination. To avoid placing the adjuster in such a situation it is recommended that the medication request be submitted through Utilization Review only to the extent to determine if the medication falls within the MTUS Treatment Guidelines.

There are Utilization Review companies that simply will not consider review of exempt medications. Education is warranted for those companies so that they understand medical review is appropriate and limited as outlined above.  Claims adjustors should not be subjected to making medical determinations.

In summary: exempt medications can be reviewed only to the extent to determine if the prescribed medication is in accordance with the MTUS Treatment Guidelines.

 Written by Alvin Webber, Associate Attorney in our Stockton Office, September 2018.

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