PDFWAC 296-20-03011

What general limitations are in place for drugs?

(1) Amount dispensed. The department or self-insurer will pay for no more than a thirty-day supply of a drug dispensed at any one time except in pension cases (see subsection (6) of this section) and claims that are held open for life-sustaining treatment. In these cases, up to a ninety-day supply of the drug is payable when:
• Coverage has been authorized; and
• The drug is not a controlled substance; and
• The drug is obtained through a designated provider.
(2) Over-the-counter drugs. Prescriptions for over-the-counter items may be paid. Special compounding fees for over-the-counter items are not payable.
(3) Generic drugs or interchangeable biological products. Generic drugs or interchangeable biological products must be dispensed when available unless the provider specifically indicates that substitution is not permitted.
(4) Evidence-based prescription drug program. In accordance with RCW 70.14.050, the department in cooperation with other state agencies may develop a preferred drug list. Any pharmacist filling a prescription for participating state purchased health care programs shall dispense the preferred drug in accordance with the endorsing practitioner therapeutic interchange program (see WAC 182-50-200).
(5) Prescriptions for unrelated medical conditions. The department or self-insurer may consider temporary coverage of prescriptions for conditions not related to the industrial injury when such conditions are retarding recovery. Any treatment for such conditions must have prior authorization per WAC 296-20-055. This would apply to any prescription for such conditions even when the endorsing practitioner indicates "dispense as written."
(6) Pension cases. When the worker is placed on a pension, the department or self-insurer may pay, at the sole discretion of the supervisor of industrial insurance, for only those drugs authorized for continued medical treatment of previously accepted conditions:
(a) Coverage must be authorized before the treatment is rendered.
(b) Controlled substances used to treat continuing pain resulting from an industrial injury or occupational disease are not payable.
[Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 17-16-133, § 296-20-03011, filed 8/1/17, effective 9/1/17; WSR 13-12-024, § 296-20-03011, filed 5/28/13, effective 7/1/13; WSR 07-17-167, § 296-20-03011, filed 8/22/07, effective 9/22/07. Statutory Authority: RCW 51.04.020, 70.14.050. WSR 04-08-040, § 296-20-03011, filed 3/30/04, effective 5/1/04. Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03011, filed 12/7/99, effective 1/20/00.]