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Drug Coverage Policies

Below is a list of policies relating to drug coverage, including limitations, criteria for coverage and treatment guidelines.


Covered by workers comp?
For more information, select the link below or call the Preferred Drug List Hotline at 1-888-443-6798. Yes No
With proper documentation Only with pre-authorization On a case-by-case basis
Antiepileptic drugs (AEDs) for neuropathic pain X
drug limitations
   
Benzodiazepines, see
WAC 296-20-03014(4)
X
time limitations
   
Botulinum toxin X  
Buprenorphine oral products  
X
   
Buprenorphine (Butrans) Transdermal System    
X
 
Compounded drug products  
X
   
Carisoprodol products   X
Duloxetine for chronic musculoskeletal pain (Effective March 1, 2013)       X
Fentanyl transmucosal products    X
Fentanyl transdermal products (Duragesic ®)   X 
Hyaluronic Acid/Viscosupplementation X  
Local anesthetics - Lidocaine patch (Lidoderm ®) and lidocaine / prilocaine cream (EMLA ®) X  
Medical food or "co-pack" products       X
Post-exposure Prophylaxis (PEP) X      
Propanolol for anxiety symptoms (Effective March 1, 2013)   X    
Opioids for non-cancer pain X  
Sedative-hypnoticsX
time limitations
   
Smoking cessation products   X 
Tramadol productsX   

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