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Prescribing Patterns

Many group practices have placed restrictions upon samples and “gifts” from pharmacy representatives since various publications have shown a link between prescribing costs and the presence (or absence) of these representatives {i.e. Caudill TS et al. Physicians, pharmaceutical sales representatives, and the cost of prescribing. Arch Fam Med. 1996 Apr;5(4):201-6.} Individuals involved in claims management need to remain acutely aware of these risks as well because the physician prescribing patterns persist.

The Official Disability Guidelines has developed a drug formulary which combines evidence-based literature recommendations regarding medications with the cost-effectiveness of these medications. This formulary classifies the drug as either a “Y” drug or an “N” drug. Intuitively, one can figure out that a “Y” drug is supported by evidence-based literature, is generally cost-effective, and could have an appropriate use in a workers’ compensation claim. An “N” drug however, would likely not be supported by evidence-based literature and/or is not considered cost-effective. As such, its use in workers compensation should be closely scrutinized.

The use of an “N” drug can be established through adequate documentation. Perhaps the claimant has a medical condition which precludes the claimant’s ability to swallow pills. Perhaps the claimant has failed attempts of multiple “Y” drugs without sustained benefit – leaving only the “N” drug to attempt. Perhaps there’s a legitimate reason that a designer cocktail of compounded medications is necessary. But to quote Ludwid Mies van der Rohe, “The Devil is in the detail.” Absent these well-documented rationales, one cannot support the necessity of these medications.

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Claims Eval