Friday, June 29, 2018
Friday, June 1, 2018
TDI Guidelines on Pharmaceutical Benefits
TITLE
28. INSURANCE
PART 2. TEXAS DEPARTMENT OF INSURANCE,
DIVISION OF WORKERS’
COMPENSATION
CHAPTER 134: BENEFITS--GUIDELINES FOR MEDICAL SERVICES,
CHARGES, AND PAYMENTS
SUBCHAPTER
F: PHARMACEUTICAL BENEFITS
Title
28 Texas Administrative Code (TAC) §134.500, §134.530 and §134.540
1. INTRODUCTION. The
Commissioner of Workers’ Compensation (commissioner), Texas Department of
Insurance, Division of Workers’ Compensation (division) adopts amendments to 28
Texas Administrative Code (TAC) §134.500, Definitions;
and adopts conforming amendments to 28 TAC §134.530, Requirements for Use of the Closed Formulary for Claims Not Subject to
Certified Networks; and 28 TAC §134.540, Requirements for Use of the Closed Formulary for Claims Subject to
Certified Networks. The changes amend the definition of the closed
formulary to exclude any prescription drug created through compounding, and to
require preauthorization for all prescription drugs created through
compounding.
The amendments are adopted without changes to
the proposed text published in the January 19, 2018, issue of the Texas Register (43 TexReg 319). In accordance with Government Code §2001.033,
the division’s reasoned justification for these amended sections is set out in
this order, which includes the preamble and the rules. The preamble contains a summary of the
factual basis for the rules, a summary of comments received from interested
parties, names of the entities that commented and whether they were in support
of, or in opposition to, the adoption of the rules, and the reasons why the
division agrees or disagrees with the comments and recommendations.
The public comment period ended on February 20,
2018. The commissioner conducted a
public hearing on February 15, 2018.
2. REASONED JUSTIFICATION. House
Bill 7 (HB 7), enacted by the 79th Texas Legislature, Regular
Session, amended Labor Code §408.028, Pharmaceutical
Services, to require that the commissioner of workers’ compensation adopt a
closed formulary. After extensive collaboration with system participants,
including health care providers and insurance carriers, the commissioner
adopted a series of rules to implement the closed formulary and transition
injured employees’ claims to the closed formulary. As adopted, the closed formulary applies to
network and non-network claims, regardless of the injured employee's date of
injury.
Implementation of the closed formulary has had
a significant effect on the use of pharmaceuticals in the Texas workers’
compensation system. The use of opioids and other potentially addictive drugs
by injured employees has decreased dramatically. Likewise, the cost for
pharmaceuticals has decreased significantly since the initial applicability of
the closed formulary. These changes have been monitored through a series of
reports issued by the Texas Department of Insurance Workers’ Compensation
Research and Evaluation Group (REG).
From 2010 to 2015, total payments for all
prescriptions decreased by 38%. In contrast, total payments for compounded
drugs increased by 98% over the same time period.
Pharmacy services for new claims (by injury
year):
Between Fiscal Injury
Year (FIY) 2011 (pre-formulary) and FIY 2012 (post-formulary), the number of
injured employees receiving N-drugs (drugs identified with a status of “N” in
the current edition of the Official Disability Guidelines Treatment in Workers’
Comp (ODG) / Appendix A, ODG Workers’ Compensation Drug Formulary, and any
updates) decreased by 67%.
N-drug costs decreased
by 78%, and N-drug costs as a percentage of all drug costs decreased by 74%
(from 20% of total to 5% of total).
The average number of
N-drug prescriptions per claim decreased by 32%.
The number of N-drug
prescriptions decreased by more than 70% across all drug groups.
Pharmacy services for
all claims (new and legacy claims by service year):
Between Fiscal Service
Year (FSY) 2011 (pre-formulary) and FSY 2014 (post-formulary for legacy
claims), the number of injured employees receiving N-drugs decreased by 83%.
The number of N-drug
prescriptions decreased by 85%.
N-drug costs decreased
by 80%. The number of N-drug prescriptions decreased by more than 80% in all
drug groups. Costs decreased by more than 70% in all drug groups.
As a result of concerns expressed by system
participants and the division’s obligation to monitor the closed formulary,
generally, analysis of compounded drug activity was undertaken based on
pharmacy data collected by the division. The following observations, presented
by the division to the Texas House of Representatives Business and Industry
Committee, are noteworthy.
Compounded drug
payments increased from $5.87 million (4% of total prescription reimbursement)
in calendar year (CY) 2010 to $11.6 million (12% of total prescription reimbursement)
in CY 2015.
Pharmacy medical
billing data indicates a 14% increase in the number of compounded drugs paid
from CY 2010 to CY 2014.
Reimbursement per
compounded drug increased 141% from CY 2010 to CY 2015 ($316 to $760).
From FY 2010 to FY
2014, ingredient costs for a selected group of ten commonly compounded drugs
increased between 82% and 1,474%.
Per the division’s analysis, as the use of
compounded drugs for work-related injuries has increased over the last five
years, the cost of compounded drugs as a percentage of total pharmacy costs has
more than doubled.
In response to these findings, the division
initiated a plan-based audit of several doctors prescribing compounded drugs in
the system. The audit was conducted by the division’s Office of the Medical
Advisor.
Under Labor Code §408.021, Entitlement to Medical Benefits, an injured employee who sustains a
compensable injury is entitled to all health care reasonably required by the
nature of the injury as and when needed. More specifically, an injured employee
is entitled to health care that cures or relieves the effects naturally
resulting from the compensable injury; promotes recovery; or enhances the
ability of the employee to return to or retain employment.
While entitlement to health care does extend
to, and include, compounded drugs, compounded drugs are not recommended as a
first-line therapy by the current edition of the division’s adopted treatment
guidelines, the Official Disability
Guidelines-Treatment in Workers’ Comp (ODG), and the medical necessity and efficacy of compounded drugs is not
well-established per evidence-based medicine standards.
The purpose of the Compound Medications
Plan-Based Audit was to promote the delivery of quality health care in a
cost-effective manner, including protection of injured employee safety; to
ensure that doctors adhere to the ODG / Appendix
A, ODG Workers’ Compensation Drug
Formulary and medically-accepted standards of care for prescribing
compounded drugs; and to determine the appropriateness of medical decision-making
related to the prescription of compounded drugs by doctors or those acting
under their supervision. The division found that prescribing doctors selected
for the audit generally did not demonstrate or document the efficacy or medical
necessity of the prescribed compounded drugs dispensed to injured employees.
The adopted amendments are necessary to ensure
that compounded drugs are prescribed to injured employees only when reasonably
required and medically necessary to treat the injured employee’s injury. Preauthorization of compounded drug
prescriptions assures that the prescription comports with the commissioner’s
adopted treatment guidelines or the network’s treatment guidelines and other
treatment standards outlined in the Insurance Code and Texas Administrative
Code. Preauthorization may also apply
downward pressure on compounded drug system costs because only compounded drugs
determined to be medically necessary will be dispensed to injured
employees. Of considerable importance,
these rule amendments clarify for stakeholders the division’s requirements
regarding compounded drugs in the closed formulary.
Until now, §134.530, Requirements for Use of the Closed Formulary for Claims Not Subject to
Certified Networks, and §134.540, Requirements
for Use of the Closed Formulary for Claims Subject to Certified Networks,
required preauthorization for “any compound that contains a drug identified
with a status of “N” in the current edition of the ODG Treatment in Workers’
Comp (ODG) / Appendix A, ODG Workers’ Compensation Drug Formulary, and any
updates.” The division did not require preauthorization for compounded drugs
that did not contain an “N” drug. The adopted rule amendments require
preauthorization for all compounded drugs prior to being dispensed, including
compounded drugs that do not contain an “N” drug.
The most efficient means for requiring
preauthorization is to amend the definition of closed formulary contained in
§134.500, Definitions, to exclude not
only compounded drugs that contain N-status drugs, but all compounded drugs. By
making conforming changes to §134.530 and §134.540, all compounded drugs
require preauthorization prior to dispensing.
Therefore, the division adopts amendments to
§134.500 to exclude from the closed formulary “any prescription drug created
through compounding.” The division uses the phrase “any prescription drug
created through compounding” rather than “compound drug” or “compound” because
“compounding” is a defined term. In §134.500, “compounding” is defined as the
preparation, mixing, assembling, packaging, or labeling of a drug or device
under a number of specified circumstances. By contrast, “compound drug” and
“compound” are not defined terms in the Texas Workers’ Compensation Act or
division rules and using them could produce more confusion than clarity within
the regulated community. The phrase “compounded drug” as used in this preamble
is shorthand for “any prescription drug created through compounding” and is the
term used in the REG’s most recent study on the topic.
Section 134.530(b)(1) and §134.540(b) require
preauthorization for drugs excluded from the closed formulary. Therefore, the
effect of amending the definition of the closed formulary to exclude any prescription
drug created through compounding is to require preauthorization of these drugs
before they are dispensed. This change does not prohibit the use of compounded
drugs for injured employees when medically necessary; however, it does require
that the medical necessity be determined prior to dispensing these drugs.
Prescriptions for compounded drugs not
requiring preauthorization that are written before July 1, 2018, and refills
for those prescriptions, will not be impacted by this rule change. However, any
prescription drug created through compounding will require preauthorization
when both prescribed and dispensed on or after July 1, 2018. The delayed
applicability date should allow sufficient time for the prescribing doctor,
injured employee, and insurance carrier to revisit and review an injured
employee’s need for specific prescription compounded drugs. As compounded drugs
are transitioned into the preauthorization process, the likelihood of
unreasonable risk of medical emergency resulting from an adverse determination
is low. However, an unreasonable risk of medical emergency triggered by an
adverse determination of a preauthorization request for a previously prescribed
and dispensed compounded drug can be addressed promptly through the process outlined
in §134.550, Medical Interlocutory Order.
3. SUMMARY OF COMMENTS AND
AGENCY RESPONSE.
General:
Commenters expressed support for the proposal. Commenters stated that preauthorization of
compounded drugs will protect injured employees by ensuring that such
medications are medically necessary, reasonably required and appropriate prior
to being dispensed. Commenters stated
that the adopted amendments are consistent with the Labor Code’s requirement
that the closed formulary be evidence-based.
A commenter stated that the adopted amendments ensure that a
prescription for compounded drugs comports with the division’s adopted
treatment guidelines or network guidelines and other treatment standards
outlined in the Insurance Code and Texas Administrative Code. Commenters stated that the cost and use of
compounded drugs has increased over the past several years but that these
adopted amendments should reduce compounded drug system costs and compounded
drug utilization. Commenters stated that
the adopted amendments will clarify for stakeholders the division’s
requirements regarding compounded drugs and reduce litigation costs created
under the division’s current rule.
Agency Response: The division appreciates the support and
agrees that the adopted rules comport with the division’s adopted
evidence-based treatment guidelines and that injured employees continue to have
access to medically-necessary and efficacious compounded drugs after approval
through the preauthorization process.
The division agrees that compounded drugs costs have increased and
preauthorization should lead to some downward pressure to reduce costs. Further, clarity in administrative processes
may reduce the instances of disputes and their related costs.
General:
Commenters stated that preauthorization of compounded drugs is not
required for initial pharmaceutical coverage, in emergency medical care
situations, and for inpatient medical care.
Agency Response: The division agrees that preauthorization is
not required for initial pharmaceutical coverage as outlined in 28 TAC
§134.501, Initial Pharmaceutical Coverage,
nor is preauthorization required for emergency medical care situations. Compounded drugs filled under these
circumstances are, however, subject to retrospective review for medical
necessity. The division notes that the
closed formulary does not apply to inpatient medical care.
General:
Commenters stated that other state and federal workers’ compensation jurisdictions
require that compounded drugs be preauthorized.
Agency Response: The division recognizes that other state and
federal workers’ compensation jurisdictions may require that compounded drugs
be preauthorized. The division notes
that each jurisdiction may have unique rationale for those decisions. The division has determined that
preauthorization of compounded drugs assures that Texas’ injured employees have
access to medically necessary and efficacious compounded drugs.
General:
A commenter stated that the adopted amendments ensure that injured
employees receive the health care guaranteed by Labor Code §408.021.
Agency Response: The division agrees that injured employees
are entitled to medical benefits as outlined in §408.021. While entitlement to health care does extend
to, and include, compounded drugs when proven medically necessary, compounded
drugs are not recommended as a first-line therapy by the current edition of the
ODG, the division’s adopted treatment guidelines, nor is the medical necessity
and efficacy of compounded drugs well-established per evidence-based medicine
standards. Therefore, all compounded
drugs are available to an injured employee after medical necessity is
determined using the preauthorization process.
General:
A commenter stated that the division’s proposal addresses the difficulty
of verifying the “N” drug status for powder-form ingredients by requiring all
compounded drugs to be preauthorized.
Agency Response: The division notes that requiring
preauthorization for all compounded drugs will provide clarity for system
participants.
General:
A commenter stated that if preauthorization is denied, the injured
employee, treating doctor or pharmacy can request an independent review of the
disputed prescription under division rule 133.308.
Agency Response: The division agrees that a requestor has
access to the medical dispute resolution process under 28 TAC §133.308, MDR of Medical Necessity Disputes. The division clarifies that a requestor may
pursue an independent review only after reconsideration of an adverse
determination made during the preauthorization process.
General:
Several commenters stated that since most compounded medications
dispensed in the worker’s compensation system are non FDA-approved for patient
safety and efficacy, compounded medications are investigational and
experimental drugs in most cases.
Agency Response: As stated in Labor Code §408.021, an injured
employee is entitled to all health care reasonably required by the nature of
the injury as and when needed. The
threshold question in this concept is the medical necessity of the treatment or
service as opposed to the classification of experimental or investigational
nature of the proposed health care. In
the case of these adopted amendments concerning compounded drugs,
preauthorization directly addresses the medical necessity issues, rendering
experimental or investigational determinations moot.
General:
A commenter stated that compound medications are expensive and that
injured workers do not benefit from them.
The commenter also stated that when a compound medication prescription
is retrospectively reviewed, the medication is never found to be reasonable or
necessary per the ODG.
Agency Response: The division acknowledges the comment, but
clarifies that the adoption of the amended rules will ensure that the medical
necessity of compounded drugs received by injured employees will be reviewed
prior to dispensing. This prospective review
should protect injured employees and ensure their health and safety. Although compounded drugs are not recommended
as a first line option in the division’s adopted treatment guidelines, the
utilization review process will consider and evaluate evidence and rationale
submitted with the preauthorization request.
Requirements for submission of a preauthorization request are included
in §134.600 of this title, regarding Preauthorization, Concurrent Utilization
Review, and Voluntary Certification of Health Care. Detailed information related to overcoming the
division’s adopted treatment guidelines is included in Appendix D of the ODG. Appendix D provides a process to assist
doctors in justifying their request to provide services not recommended by the
ODG treatment guidelines.
General:
A commenter opposes the division’s proposal, as published, because it
“is in essence a ban on compounded medications for injured workers due to
payers’ concern for their bottom lines.”
Agency Response: The division disagrees. Under the Texas Workers’ Compensation Act, an
injured employee who sustains a compensable injury is entitled to “all health
care reasonably required by the nature of the injury as and when needed.” More
specifically, an injured employee is entitled to health care that “cures or
relieves the effects naturally resulting from the compensable injury; promotes
recovery; or enhances the ability of the employee to return to or retain
employment.”
While entitlement to health care does extend
to, and include, compounded drugs when proven medically necessary, compounded
drugs are not recommended as a first-line therapy by the current edition of the
ODG, the division’s adopted treatment guidelines, nor is the medical necessity
and efficacy of compounded drugs well-established per evidence-based medicine
standards. Therefore, all compounded
drugs are available to an injured employee after medical necessity is
determined using the preauthorization process.
Although the division has a responsibility to
contain costs in the Texas workers’ compensation system, the purpose of these
adopted rule amendments is to focus on the medical necessity and efficacy of
drugs created through compounding. Costs
are a factor, but the purpose of preauthorization in the workers’ compensation
system is to determine the medical necessity and efficacy of proposed health care
treatments and services before they are delivered to injured employees. At the conclusion of a preauthorization
process, approval eliminates medical necessity as a rationale for a
reimbursement denial.
General:
A commenter recommended that the division create a “limited formulary of
compounded medication products” whereby the division would “(i)dentify and make
exceptions for compounded prescription therapy that provides an alternative to
the abusive and addictive side effects of oral controlled substances.” The commenter also recommended that the
division “(d)evelop a list of active pharmaceutical ingredients (APIs) in
compounds based on data that reflects improved outcomes and cost-effective
alternatives to commercially available products;” “(i)dentify these APIs in a
closed formulary; and provide incentives for identified patients with a history
or potential for abuse and addiction to seek effective compounded medication treatment.” The commenter stated that these
recommendations “(offer) immediate access to effective alternative therapies
that reduce drug costs in the system” which “benefit(s) carriers and injured
workers.”
Agency Response: The division declines to implement the
commenter’s recommendations. The
division’s adopted treatment guidelines are a compilation of the evidence basis
for services provided within the Texas workers’ compensation system. Currently,
the ODG does not recommend the use of compounded drugs as a first line option
for injured employees. If there is evidence related to the medical efficacy of
a particular or specific compounded drug, that information should be submitted
to ODG for evaluation and consideration in the context of treatment guidelines.
This process for evaluating evidence is documented on the ODG website at the
link titled “Suggest ODG Updates.”
If there are reasons that a drug created
through compounding should be considered an appropriate alternative to another
drug or treatment protocol for a specific injured employee, that rationale
should be documented and submitted with the preauthorization request. ODG’s Appendix D – Documenting Exceptions to
the Guidelines provides guidance on documenting exceptions to the guidelines.
General:
A commenter advised the division to “recognize and account for reducing
duplicate opioid therapy or other controlled substances from current
practices.”
Agency Response: The division clarifies that at the direction
of the Legislature, the division has adopted evidence-based treatment
guidelines and a pharmacy closed formulary.
Further, the closed formulary rules apply to certified networks and the
evidence-based guidelines applicable to the certified network. These actions have led to a significant
decrease in the use of opioids and other dangerous drugs in the Texas workers’
compensation system. The medical necessity justification of a drug created
through compounding as an alternative to the use of another prescription drug,
or another treatment, may be made through the preauthorization process.
General:
A commenter recommended that the division should “(c)onsider ‘maximum
allowable costs’ to appropriate therapy that meets the goals” of ensuring
“effective and appropriate use of less risky alternatives” and “(a)ligns with
the Texas Legislature’s goal to reduce opioid use and addiction among Texans.”
Agency Response: The division disagrees as this comment is
outside the scope of the amended rules, which do not address reimbursement of
pharmaceuticals. The changes to the
closed formulary are primarily concerned with the medical efficacy and the
medical necessity of drugs created through compounding. The division agrees that appropriate use of
health care is important and believes that requiring preauthorization for drugs
created through compounding assures the medical necessity of the prescribed
compounded drug. The division
implemented a closed formulary at the direction of the Legislature and as a result,
use of drugs excluded from the closed formulary, including opioids, has
declined significantly and has been identified as a model for other states’
workers’ compensation programs.
General:
A commenter stated that “health plans often use prior authorization as a
means of delaying, and likely denying care, ultimately interfering with
appropriate clinical care.” The
commenter stated that “(p)hysicians who believe compounding medications are the
most appropriate approach, will likely discontinue this course of treatment due
to increased administrative challenges.”
Another commenter stated that “requiring preauthorization for all
compounds is not in the best interest of the health and safety of our state’s
injured workers” because “it will only lead to more administrative costs for
insurance carriers, pharmacists and health care providers, while also threatening
the health and recovery of the state’s injured workers.”
Agency Response: The division disagrees that preauthorization
interferes with appropriate clinical care.
Since compounded drugs are not recommended as a first line therapy
option in the division’s adopted treatment guidelines, the utilization review
process considers and evaluates evidence and clinical rationale submitted with
the preauthorization request.
Consequently, the adopted rule amendments will ensure that compounded
drugs received by injured employees are medically necessary and reviewed prior
to dispensing. This process of obtaining
preauthorization for compounded drugs is the same as for any drug excluded from
the closed formulary or other treatment or service that requires preauthorization. In short, preauthorization is not about
delaying or denying care, nor is it intended to create administrative
challenges. Rather, preauthorization is
an opportunity to justify recommended health care for an injured employee while
assuring their health and safety.
General:
A commenter stated that compounded drugs benefit injured employees and
“significantly improves pain and return-to-work timeframes.”
Agency Response: Although the division has not been presented
with any data that specifically supports this categorical statement, the
statute requires that only medically necessary services be provided to injured
employees. In general, medically
necessary and appropriate health care leads to better treatment outcomes and
return-to-work time frames. After
medical necessity is determined using the preauthorization process, the
preauthorized compounded drug is available to the injured employee.
General:
A commenter wrote that “(d)ecisions on patient health should be
determined through the triad relationship of patient, physician, and
pharmacist.”
Another commenter wrote that a pharmacist is
best situated to obtain preauthorization because of his/her “in-depth knowledge
of a prescribed compound and the duty to dispense medicine.” The commenter continued that requiring a
doctor to obtain preauthorization is outside “a doctor’s scope of practice.”
Agency Response: The division notes that the physician-patient
relationship is the cornerstone of medical care. It is the responsibility of the prescribing
physician to order compounded drugs and document their medical necessity. A pharmacist is not a physician; a pharmacist
dispenses medication at the direction of a physician. The physician’s duty is to the patient; the physician
does not abdicate that responsibility to the pharmacist. However, the cooperation between health care
providers and injured employee is important in developing the appropriate
course of treatment to facilitate early and appropriate return-to-work. In the Texas workers’ compensation system, the
treating doctor is responsible for coordinating services necessary for the
injured employee’s recovery and is best positioned to understand the factors
related to the injury and is best positioned to make the case for the medical
necessity of a particular treatment or service.
Pharmacists, like other ancillary health care providers, are available
to assist and advise the treating doctor or prescribing doctor when
appropriate.
General:
Commenters stated that compounds are needed by injured employees unable
to swallow oral medications, or are allergic to other medications, and those
with burn injuries. A commenter stated
that compounds are also a safe alternative to addictive drugs. Another commenter stated that “the Food and
Drug Administration recognizes that compounding drugs can serve important
patient needs.”
Agency Response: The division agrees and restates that compounded
drugs are not being excluded as a treatment option for injured employees. For example, in situations where an injured
employee is unable to swallow oral medications or is allergic to other
medications, compounded drugs may be appropriate for specific injured employees. This is consistent with the information
concerning compounding contained in the ODG.
The preauthorization process is the avenue for prescribing doctors to
establish the medical necessity and appropriateness of the compounded drug.
General:
A commenter opined that compounds used for pain relief improve
return-to-work outcomes because they only affect the site of pain and are not
systemic and therefore reduce the overall costs to the workers’ compensation
system. Another commenter stated that
compounds that are made for transdermal pain relief can be delivered directly
to the site of the injury without subsequent side effects and can lead to a
faster recovery for the patient. Another
commenter wrote that “(w)hen a compound is used for pain relief, it only
affects the site of the pain and is not systemic.”
Agency Response: The division disagrees. The division has received no data or
documentation that identifies compounded drugs as a more effective treatment
option than other services or treatments to improve return-to-work outcomes,
and therefore, does not establish overall cost reduction to the system. Further, the division’s medical advisor
disagrees and notes that there is no published data that supports the notion
that compounded drugs do not have a systemic effect.
General:
A commenter wrote that preauthorization for all compounds delays the
recovery of injured employees and their return-to-work because of the
administrative costs and time involved in obtaining preauthorization which may
be revoked later through retrospective review.
Agency Response: The division disagrees that preauthorization
of compounded drugs will delay recovery and return-to-work of injured
employees. The time frames for the
approval of preauthorization of compounded drugs is consistent with the time
frames for any prescription or service that requires preauthorization. Generally, this process is required to be
completed within three working days. If
preauthorization is obtained, medical necessity of the compounded drug is not
subject to retrospective review. This
activity assures that pharmacy bills are not denied by an insurance carrier for
medical necessity purposes after the prescription has been dispensed to the
injured employee. Billing for the claim
must meet the requirements of the rules related to billing and
reimbursement. However, the claim is
subject to the other administrative questions of compensability, extent, and
liability.
General:
A commenter wrote that rather than requiring preauthorization for all
compounds, “Texas (should) set a reasonable cap on compound medications and
require preauthorization for any compound that exceeds the cap.” The commenter stated that “(r)equiring
preauthorization on the most expensive drugs will help ensure that the costs to
the workers’ compensation system are reduced, while not endangering an injured
worker’s access to needed medication.”
Agency Response: The division disagrees that requiring
preauthorization endangers an injured employee’s access to compounded
drugs. Injured employees have access to
compounded drugs when medical necessity is determined. Compounded drugs will be
treated like any other drug requiring preauthorization. Although the division has a responsibility to
control costs in the Texas workers’ compensation system, the primary reason for
preauthorization is to assure that medically necessary and efficacious
compounded drugs are available to injured employees. Medical necessity remains a constant while
the cost of a compounded drug may be impacted by the volume or frequency of use
of the compounded drug.
General:
The commenter “believes the proposed changes have the potential to harm
injured workers” and “will delay or deny access to health care for our state’s
injured workers.”
Agency Response: The division disagrees. Preauthorization will assure that only
medically necessary compounded drugs are dispensed to injured employees. The
time frames for the approval of preauthorization of compounded drugs is
consistent with the time frames for any prescription or service that requires
preauthorization. Generally, this
process is required to be completed within three working days. Details of these processes and time frames
are contained in Texas Department of Insurance and division rules, specifically
as outlined in Chapters 10, 19, 134, and 137 of this title (relating to Workers’ Compensation Health Care Networks,
Licensing and Regulation of Insurance
Professionals, Benefits-Guidelines
for Medical Services, Charges and Payments, and Disability Management, respectively). These time frames are not currently a barrier
to the timely provision of health care, including prescriptions.
General:
A commenter stated that it “believes that the division’s decision to
exclude prescriptions and refills that are written prior to July 1, 2018, will
avoid disruptions in injured employees’ medical treatment.”
Agency Response: The division agrees and appreciates the
supportive comment.
General:
A commenter stated that the division has elected to rely on medical
interlocutory orders under 28 TAC §134.550 to address the needs of injured
employees with allergies or disabilities instead of providing exceptions in the
body of the rule. The commenter noted
that the process for seeking a medical interlocutory order is not simple since
health care providers seeking medical interlocutory orders to obtain compounded
drugs for injured employees must request preauthorization, submit a detailed request
for a medical interlocutory order and submit a request to a utilization review
agent. The commenter stated that none of
these submissions are currently required for obtaining a compounded drug that
does not contain an “N” status drug.
Agency Response: The division disagrees. The adopted rule requires prescribing doctors
to submit a preauthorization request that outlines the medical necessity of a
compounded drug. The division restates
that compounded drugs are not being excluded as a treatment option for injured
employees. For example, in situations
where an injured employee is unable to swallow oral medications or is allergic
to other medications, compounded drugs may be appropriate for specific injured
employees. This is consistent with the
information concerning compounding contained in the ODG.
The division clarifies that the
preauthorization process is the avenue for prescribing doctors to establish the
medical necessity and appropriateness of the compounded drug. Further, the division notes that a request
for a medical interlocutory order for a compounded drug is only appropriate
after a compounded drug has been previously prescribed and dispensed to an
injured employee; an adverse determination has been made for a new prescription
of the compounded drug; and the doctor states that there is the potential for
an unreasonable risk of medical emergency for the injured employee.
General:
A commenter suggested “that the Division develop a robust public
education effort to insure that all injured employees, pharmacists and other
medical providers are aware of the medical interlocutory order process and all
the steps required to obtain an interlocutory order.”
Agency Response: The division agrees that education of system
participants is an important part of the rule implementation process. Toward that end, the division engaged in
significant efforts to assure the successful implementation of the closed
formulary and will continue to incorporate information regarding this and any
other rule changes into its ongoing outreach activities to injured employees, health
care providers and insurance carriers.
General:
A commenter stated that “(c)ompounded drugs, including transdermal pain
creams, contribute to the recovery of injured workers when they experience back
pain.” The commenter also stated that “(t)ransdermal
compounds also provide an injured worker a safe alternative to some of our
country’s addictive drugs.”
Agency Response: The division restates that injured employees
continue to have access to medically necessary compounded drugs by pursuing
preauthorization under the adopted rule.
If a compounded drug is an appropriate medically necessary alternative
to an addictive drug, the prescribing doctor should include that information
and rationale for the use of the compounded drug in the preauthorization
request.
General:
Several commenters expressed opposition to the rule and provided
information that endorsed use of compounds in their particular case and
expressed concern that they would not be able to receive a compounded
medication as a result of this rule. Another commenter urged the commissioner to
continue making compounded drugs accessible without a requirement of
preauthorization.
Agency Response: The division disagrees that injured employees
will not be able to receive medically necessary compounded medications as a
result of this rule. An injured employee
who sustains a compensable injury is entitled by statute to receive “all health
care reasonably required by the nature of the injury as and when needed.” More specifically, an injured employee is
entitled by statute to health care that “cures or relieves the effects
naturally resulting from the compensable injury; promotes recovery; or enhances
the ability of the employee to return to or retain employment.”
While entitlement to health care does extend
to, and includes, compounded drugs, compounded drugs are generally not
recommended as a first-line therapy by the current edition of the division’s
adopted treatment guidelines, the ODG,
and the medical necessity and efficacy of compounded drugs is not
well-established per evidence-based medicine standards. Preauthorization of drugs created through
compounding will assure that only medically necessary compounded drugs are dispensed
to injured employees.
4. NAMES OF THOSE COMMENTING FOR AND AGAINST THE
PROPOSAL.
For:
American Airlines Group; CompPharma; Healthesystems; Insurance Council
of Texas; Mitchell; myMatrixx; National Association of Mutual Insurance
Companies; Optum Workers’ Compensation and Auto No-Fault Division; Office of
Injured Employee Counsel; Property Casualty Insurers Association of America;
State Office of Risk Management.
Against:
Alliance of Independent Pharmacists of Texas; Memorial Compounding
Pharmacy; Texas AFL-CIO; several individuals on behalf of themselves.
Neither for or against: AIG.
5. STATUTORY AUTHORITY.
The amendments are adopted under the authority
of Labor Code §402.00111, Relationship
Between Commissioner of Insurance and Commissioner of Workers’ Compensation;
Separation of Authority; Rulemaking; Labor Code §402.00116, Chief Executive; Labor Code §402.00128, General Powers and Duties of Commissioner;
Labor Code §402.061, Adoption of Rules;
Labor Code §408.021, Entitlement to
Medical Benefits; Labor Code §408.028, Pharmaceutical
Services; Labor Code §413.011, Reimbursement
Policies and Guidelines; Treatment Guidelines and Protocols; Labor Code
§413.013, Programs; Labor Code
§413.014, Preauthorization Requirements;
Concurrent Review and Certification of Health Care; Labor Code §413.053, Standards of Reporting and Billing;
Insurance Code, Chapter 1305, Workers’
Compensation Health Care Networks; Insurance Code §4201.054, Workers’ Compensation Benefits; and
Occupations Code §551.003, Definitions.
Labor Code §402.00111 states that the
commissioner of workers’ compensation shall exercise all executive authority,
including rulemaking authority, under the Texas Workers’ Compensation Act.
Labor Code §402.00116 states that the
commissioner of workers’ compensation is the division’s chief executive and
administrative officer and shall administer and enforce the Texas Workers’
Compensation Act, other workers’ compensation laws of this state, and other
laws granting jurisdiction to or applicable to the division or the commissioner
of workers’ compensation.
Labor Code §402.00128 states that the commissioner
of workers’ compensation shall conduct the daily operations of the division and
otherwise implement division policy and, among other functions, may delegate;
assess and enforce penalties; and enter appropriate orders.
Labor Code §402.061 states that the
commissioner shall adopt rules as necessary for the implementation and
enforcement of the Texas Workers’ Compensation Act.
Labor Code §408.021 states that an employee who
sustains a compensable injury is entitled to all health care reasonably required
by the nature of the injury as and when needed.
Labor Code §408.028 states that the
commissioner of workers’ compensation by rule shall adopt a closed formulary
under §413.011 and that rules adopted by the commissioner of workers’
compensation shall allow an appeals process for claims in which a treating
doctor determines and documents that a drug not included in the formulary is
necessary to treat an injured employee’s compensable injury. In addition, this
section states that the commissioner of workers’ compensation shall by rule
require the use of generic pharmaceutical mediations and clinically appropriate
over-the-counter alternatives to prescription medications unless otherwise
specified by the prescribing doctor, in accordance with applicable state law.
Labor Code §413.011 requires the commissioner
of workers’ compensation to adopt by rule treatment guidelines and
return-to-work guidelines and medical policies designed to ensure the quality
of medical care and to achieve effective medical cost control.
Labor Code §413.013 requires the commissioner
to establish by rule a program for prospective, concurrent, and retrospective
review and resolution of a dispute regarding health care treatments and
services, and its monitoring.
Labor Code §413.014 states that the
commissioner of workers’ compensation by rule shall specify which health care
treatments and services require express preauthorization or concurrent review
by the insurance carrier. If a specified health care treatment or service is
preauthorized as provided by this section, that treatment or services is not
subject to retrospective review of the medical necessity of the treatment or
service.
Labor Code §413.053 states that the
commissioner by rule shall establish standards of reporting and billing
governing both form and content.
Insurance
Code, Chapter 1305 is the Workers’ Compensation Health Care Network Act and
contains treatment guidelines and authorization requirements applicable to
certified networks.
Insurance Code §4201.054 states that the
commissioner of workers’ compensation shall regulate as provided by Chapter
4201 a person who performs utilization review of a medical benefit provided
under Title 5, Labor Code, and that the commissioner of workers’ compensation
may adopt rules as necessary to implement section 4201.054.
Occupations Code §551.003 provides the
definitions for “compounding” and “substitution.”
6. TEXT.
§134.500 Definitions
The following words and terms, when used in
this subchapter, have the following meanings, unless the context clearly
indicates otherwise:
(1) Brand name drug--A drug marketed under a proprietary,
trademark-protected name.
(2) Certified workers' compensation health care network (certified
network)--An organization that is certified in accordance with Insurance Code
Chapter 1305 and department rules.
(3) Closed formulary--All available Food and
Drug Administration (FDA) approved prescription and nonprescription drugs
prescribed and dispensed for outpatient use, but excludes:
(A) drugs identified with a status of
"N" in the current edition of the Official Disability Guidelines
Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation
Drug Formulary, and any updates;
(B) any prescription drug created through
compounding prescribed before July 1, 2018 that contains a drug identified with
a status of “N” in the current edition of the ODG Treatment in Workers’ Comp (ODG) / Appendix A, ODG Workers’ Compensation Drug Formulary,
and any updates;
(C) any prescription drug created through
compounding prescribed and dispensed on or after July 1, 2018; and
(D) any investigational or experimental drug
for which there is early, developing scientific or clinical evidence
demonstrating the potential efficacy of the treatment, but which is not yet
broadly accepted as the prevailing standard of care as defined in Labor Code
§413.014(a).
(4) Compounding--As defined under Occupations Code §551.003(9),
the preparation, mixing, assembling, packaging, or labeling of a drug or
device:
(A) as the result of a practitioner's prescription drug order
based on the practitioner-patient-pharmacist relationship in the course of
professional practice;
(B) for administration to a patient by a practitioner as the
result of a practitioner's initiative based on the practitioner-patient-pharmacist
relationship in the course of professional practice;
(C) in anticipation of a prescription drug order based on a
routine, regularly observed prescribing pattern; or
(D) for or as an incident to research, teaching, or chemical
analysis and not for selling or dispensing, except as allowed under Occupations
Code §562.154 or Occupations Code Chapter 563.
(5) Generic--See generically equivalent in definition of paragraph
(6) of this section.
(6) Generically equivalent--As defined under Occupations Code
§562.001, a drug that, when compared to the prescribed drug, is:
(A) pharmaceutically equivalent--Drug products that have identical
amounts of the same active chemical ingredients in the same dosage form and
that meet the identical compendia or other applicable standards of strength,
quality, and purity according to the United States Pharmacopoeia or another
nationally recognized compendium; and
(B) therapeutically equivalent--Pharmaceutically equivalent drug
products that, if administered in the same amounts, will provide the same
therapeutic effect, identical in duration and intensity.
(7) Medical emergency--The sudden onset of a medical condition
manifested by acute symptoms of sufficient severity, including severe pain that
in the absence of immediate medical attention could reasonably be expected to
result in:
(A) placing the patient's health or bodily functions in serious
jeopardy; or
(B) serious dysfunction of any body organ or part.
(8) Nonprescription drug or over-the-counter medication--A non-narcotic
drug that may be sold without a prescription and that is labeled and packaged
in compliance with state or federal law.
(9) Open formulary--Includes all available Food and Drug
Administration (FDA) approved prescription and nonprescription drugs prescribed
and dispensed for outpatient use, but does not include drugs that lack FDA
approval, or non-drug items.
(10) Prescribing doctor--A physician or dentist who prescribes
prescription drugs or over the counter medications in accordance with the physician's
or dentist's license and state and federal laws and rules. For purposes of this
chapter, prescribing doctor includes an advanced practice nurse or physician
assistant to whom a physician has delegated the authority to carry out or sign
prescription drug orders, under Occupations Code Chapter 157, who prescribes
prescription drugs or over the counter medication under the physician's
supervision and in accordance with the health care practitioner's license and
state and federal laws and rules.
(11) Prescription--An order for a prescription or nonprescription
drug to be dispensed.
(12) Prescription drug--
(A) A substance for which federal or state law requires a
prescription before the substance may be legally dispensed to the public;
(B) A drug that under federal law is required, before being
dispensed or delivered, to be labeled with the statement: "Caution:
federal law prohibits dispensing without prescription;" "Rx
only;" or another legend that complies with federal law; or
(C) A drug that is required by federal or state statute or
regulation to be dispensed on prescription or that is restricted to use by a
prescribing doctor only.
(13) Statement of medical necessity--A written statement from the
prescribing doctor to establish the need for treatments or services, or
prescriptions, including the need for a brand name drug where applicable. A
statement of medical necessity shall include:
(A) the injured employee's full name;
(B) date of injury;
(C) social security number;
(D) diagnosis code(s);
(E) whether the drug has previously been prescribed and dispensed,
if known, and whether the inability to obtain the drug poses an unreasonable
risk of a medical emergency; and
(F) how the prescription treats the diagnosis, promotes recovery,
or enhances the ability of the injured employee to return to or retain
employment.
(14) Substitution--As defined under Occupations Code §551.003(41),
the dispensing of a drug or a brand of drug other than the drug or brand of
drug ordered or prescribed.
§134.530 Requirements for Use of the Closed Formulary
for Claims Not Subject to Certified Networks
(a) Applicability. The closed formulary applies
to all drugs that are prescribed and dispensed for outpatient use for claims
not subject to a certified network on or after September 1, 2011 when the date
of injury occurred on or after September 1, 2011.
(b) Preauthorization for claims subject to the
Division's closed formulary.
(1) Preauthorization is only required for:
(A) drugs identified with a status of
"N" in the current edition of the ODG Treatment in Workers' Comp (ODG)
/ Appendix A, ODG Workers' Compensation Drug Formulary, and any updates;
(B) any prescription drug created through
compounding prescribed before July 1, 2018 that contains a drug identified with
a status of "N" in the current edition of the ODG Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary,
and any updates;
(C) any prescription drug created through
compounding prescribed and dispensed on or after July 1, 2018; and
(D) any investigational or experimental drug
for which there is early, developing scientific or clinical evidence
demonstrating the potential efficacy of the treatment, but which is not yet
broadly accepted as the prevailing standard of care as defined in Labor Code
§413.014(a).
(2) When §134.600(p)(12) of this title
(relating to Preauthorization, Concurrent Review, and Voluntary Certification
of Health Care) conflicts with this section, this section prevails.
(c) Preauthorization of intrathecal drug delivery systems.
(1) An intrathecal drug delivery system requires preauthorization
in accordance with §134.600 of this title and the preauthorization request must
include the prescribing doctor's drug regime plan of care, and the anticipated
dosage or range of dosages for the administration of pain medication.
(2) Refills of an intrathecal drug delivery system with drugs
excluded from the closed formulary, which are billed using Healthcare Common
Procedure Coding System (HCPCS) Level II J codes, and submitted on a CMS-1500
or UB-04 billing form, require preauthorization on an annual basis.
Preauthorization for these refills is also required whenever:
(A) the medications, dosage or range of dosages, or the drug
regime proposed by the prescribing doctor differs from the medications, dosage
or range of dosages, or drug regime previously preauthorized by that
prescribing doctor; or
(B) there is a change in prescribing doctor.
(d) Treatment guidelines. Except as provided by this subsection,
the prescribing of drugs shall be in accordance with §137.100 of this title
(relating to Treatment Guidelines), the division's adopted treatment guidelines.
(1) Prescription and nonprescription drugs included in the
division's closed formulary and recommended by the division's adopted treatment
guidelines may be prescribed and dispensed without preauthorization.
(2) Prescription and nonprescription drugs included in the
division's closed formulary that exceed or are not addressed by the division's
adopted treatment guidelines may be prescribed and dispensed without
preauthorization.
(3) Drugs included in the closed formulary that are prescribed and
dispensed without preauthorization are subject to retrospective review of
medical necessity and reasonableness of health care by the insurance carrier in
accordance with subsection (g) of this section.
(e) Appeals process for drugs excluded from the closed formulary.
(1) For situations in which the prescribing doctor determines and
documents that a drug excluded from the closed formulary is necessary to treat
an injured employee's compensable injury and has prescribed the drug, the
prescribing doctor, other requestor, or injured employee must request approval
of the drug by requesting preauthorization, including reconsideration, in
accordance with §134.600 of this title and applicable provisions of Chapter 19
of this title (relating to Agents' Licensing).
(2) If preauthorization is being requested by an injured employee
or a requestor other than the prescribing doctor, and the injured employee or
other requestor requests a statement of medical necessity, the prescribing
doctor shall provide a statement of medical necessity to facilitate the
preauthorization submission as set forth in §134.502 of this title (relating to
Pharmaceutical Services).
(3) If preauthorization for a drug excluded from the closed
formulary is denied, the requestor may submit a request for medical dispute
resolution in accordance with §133.308 of this title (relating to MDR by
Independent Review Organizations).
(4) In the event of an unreasonable risk of a medical emergency,
an interlocutory order may be obtained in accordance with §133.306 of this
title (relating to Interlocutory Orders for Medical Benefits) or §134.550 of
this title (relating to Medical Interlocutory Order).
(f) Initial pharmaceutical coverage.
(1) Drugs included in the closed formulary which are prescribed
for initial pharmaceutical coverage, in accordance with Labor Code §413.0141,
may be dispensed without preauthorization and are not subject to retrospective
review of medical necessity.
(2) Drugs excluded from the closed formulary which are prescribed
for initial pharmaceutical coverage, in accordance with Labor Code §413.0141,
may be dispensed without preauthorization, except as referenced in subsection
(b)(1)(C) of this section, and are subject to retrospective review of medical
necessity.
(g) Retrospective review. Except as provided in subsection (f)(1)
of this section, drugs that do not require preauthorization are subject to
retrospective review for medical necessity in accordance with §133.230 of this
title (relating to Insurance Carrier Audit of a Medical Bill) and §133.240 of
this title (relating to Medical Payments and Denials), and applicable
provisions of Chapter 19 of this title.
(1) Health care, including a prescription for a drug, provided in
accordance with §137.100 of this title is presumed reasonable as specified in
Labor Code §413.017, and is also presumed to be health care reasonably required
as defined by Labor Code §401.011(22-a).
(2) In order for an insurance carrier to deny payment subject to a
retrospective review for pharmaceutical services that are recommended by the
division's adopted treatment guidelines, §137.100 of this title, the denial
must be supported by documentation of evidence-based medicine that outweighs
the presumption of reasonableness established under Labor Code §413.017.
(3) A prescribing doctor who prescribes pharmaceutical services
that exceed, are not recommended, or are not addressed by §137.100 of this
title, is required to provide documentation upon request in accordance with
§134.500(13) of this title (relating to Definitions) and §134.502(e) and (f) of
this title.
§134.540
Requirements for Use of the Closed Formulary for Claims Subject to Certified
Networks
(a) Applicability. The closed formulary applies
to all drugs that are prescribed and dispensed for outpatient use for claims subject
to a certified network on or after September 1, 2011 when the date of injury
occurred on or after September 1, 2011.
(b) Preauthorization for claims subject to the
Division's closed formulary. Preauthorization is only required for:
(1) drugs identified with a status of
"N" in the current edition of the ODG Treatment in Workers' Comp (ODG)
/ Appendix A, ODG Workers' Compensation Drug Formulary, and any updates;
(2) any prescription drug created through
compounding prescribed before July 1, 2018 that contains a drug identified with
a status of "N" in the current edition of the ODG Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary,
and any updates;
(3) any prescription drug created through
compounding prescribed and dispensed on or after July 1, 2018; and
(4) any investigational or experimental drug
for which there is early, developing scientific or clinical evidence
demonstrating the potential efficacy of the treatment, but which is not yet
broadly accepted as the prevailing standard of care as defined in Labor Code
§413.014(a).
(c) Preauthorization of intrathecal drug delivery systems.
(1) An intrathecal drug delivery system requires preauthorization
in accordance with the certified network's treatment guidelines and
preauthorization requirements pursuant to Insurance Code Chapter 1305 and
Chapter 10 of this title (relating to Workers' Compensation Health Care
Networks).
(2) Refills of an intrathecal drug delivery system with drugs
excluded from the closed formulary, which are billed using Healthcare Common
Procedure Coding System (HCPCS) Level II J codes, and submitted on a CMS-1500
or UB-04 billing form, require preauthorization on an annual basis.
Preauthorization for these refills is also required whenever:
(A) the medications, dosage or range of dosages, or the drug
regime proposed by the prescribing doctor differs from the medications dosage
or range of dosages, or drug regime previously preauthorized by that
prescribing doctor; or
(B) there is a change prescribing doctor.
(d) Treatment guidelines. The prescribing of drugs shall be in
accordance with the certified network's treatment guidelines and
preauthorization requirements pursuant to Insurance Code Chapter 1305 and
Chapter 10 of this title. Drugs included in the closed formulary that are
prescribed and dispensed without preauthorization are subject to retrospective
review of medical necessity and reasonableness of health care by the insurance
carrier in accordance with subsection (f) of this section.
(e) Appeals process for drugs excluded from the closed formulary.
(1) For situations in which the prescribing doctor determines and documents
that a drug excluded from the closed formulary is necessary to treat an injured
employee's compensable injury and has prescribed the drug, the prescribing
doctor, other requestor, or injured employee must request approval of the drug
in a specific instance by requesting preauthorization in accordance with the
certified network's preauthorization process established pursuant to Chapter
10, Subchapter F of this title (relating to Utilization Review and
Retrospective Review) and applicable provisions of Chapter 19 of this title
(relating to Agents' Licensing).
(2) If preauthorization is pursued by an injured employee or
requestor other than the prescribing doctor, and the injured employee or other
requestor requests a statement of medical necessity, the prescribing doctor
shall provide a statement of medical necessity to facilitate the
preauthorization submission as set forth in §134.502 of this title (relating to
Pharmaceutical Services).
(3) If preauthorization for a drug excluded from the closed formulary
is denied, the requestor may submit a request for medical dispute resolution in
accordance with §133.308 of this title (relating to MDR by Independent Review
Organizations).
(4) In the event of an unreasonable risk of a medical emergency,
an interlocutory order may be obtained in accordance with §133.306 of this
title (relating to Interlocutory Orders for Medical Benefits) or §134.550 of
this title (relating to Medical Interlocutory Order).
(f) Initial pharmaceutical coverage.
(1) Drugs included in the closed formulary which are prescribed
for initial pharmaceutical coverage, in accordance with Labor Code §413.0141,
may be dispensed without preauthorization and are not subject to retrospective
review of medical necessity.
(2) Drugs excluded from the closed formulary which are prescribed
for initial pharmaceutical coverage, in accordance with Labor Code §413.0141,
may be dispensed without preauthorization and are subject to retrospective
review of medical necessity.
(g) Retrospective review. Except as provided in subsection (f)(1)
of this section, drugs that do not require preauthorization are subject to
retrospective review for medical necessity in accordance with §133.230 of this
title (relating to Insurance Carrier Audit of a Medical Bill), §133.240 of this
title (relating to Medical Payments and Denials), the Insurance Code, Chapter
1305, applicable provisions of Chapters 10 and 19 of this title.
(1) In order for an insurance carrier to deny payment subject to a
retrospective review for pharmaceutical services that fall within the treatment
parameters of the certified network's treatment guidelines, the denial must be
supported by documentation of evidence-based medicine that outweighs the
evidence-basis of the certified network's treatment guidelines.
(2) A prescribing doctor who prescribes pharmaceutical services
that exceed, are not recommended, or are not addressed by the certified
network's treatment guidelines, is required to provide documentation upon
request in accordance with §134.500(13) of this title (relating to Definitions)
and §134.502(e) and (f) of this title.
7. CERTIFICATION.
This agency certifies that
legal counsel has reviewed the adoption and found it to be
a valid exercise of the agency’s legal
authority.
Issued at Austin, Texas, on ____________, 2018.
_______________________
Nicholas Canaday III
General Counsel
Texas Department of Insurance,
Division of Workers’ Compensation
The commissioner adopts amendments to
§§134.500, 134.530, and 134.540.
_________________________
W. Ryan
Brannan
Commissioner
of Workers’ Compensation
COMMISSIONER’S
ORDER NO. _________________
ATTEST:
_______________________
Nicholas Canaday III
General Counsel
Texas Department of Insurance,
Division of Workers’ Compensation
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