Initial UR & IMR Prescription Drug Outcomes Under the California Workers' Compensation Formulary (Spotlight Report, published 07/18)

A CWCI study offering a preliminary look at Utilization Review (UR) and Independent Medical Review (IMR) outcomes involving pharmaceutical requests for California injured workers after the California Workers’ Compensation Prescription Drug Formulary took effect in January 2018.  Based on data from 141,643 pharmaceutical requests and UR decisions from the first five months of 2017 and 2018, and 58,604 IMR decisions from the first four months of those same two years, the study measures and compares pre- and post-formulary UR and IMR prescription drug outcomes in in the percentage of URs and IMRs involving pharmaceutical requests; the mix of pharmaceutical UR decisions involving drugs categorized by the formulary as Exempt, Non-Exempt, or Not Listed, and the UR approval, modification, and denial rates for each category; the mix and approval rates for pharmaceutical IMR decisions involving Exempt, Non-Exempt, and Not Listed drugs; the proportion of Exempt drugs co-prescribed with Non-Exempt or Not Listed drugs reviewed by UR and IMR; and the proportion of UR and IMR decisions involving opioid requests and the UR approval and IMR uphold rates for those requests.