California DWC approves changes to its utilization review rules
At long last, the California Division of Workers’ Compensation (DWC) has published and approved changes to its utilization review (UR) rules. The rules have been approved by the Office of Administrative Law (OAL) and will take effect on April 1, 2026.
How do these changes affect pharmacy services?
- They impact the drug formulary by including an exception for certain treatments provided/prescribed by predesignated or MPN/HCO physicians within the first 30 days of injury.
- They allow for electronic submission of a Request for Authorization (RFA) via encrypted email or electronic data interchange.
- They modify certain review timeframes and limitations regarding medication review.
The Optum Public Policy and Regulatory Affairs (PPRA) team will be working with our internal teams to ensure full compliance with the updated rules and will shortly provide more in-depth information to our client partners on the changes. More information on the adopted rules can be found at this link here: https://www.dir.ca.gov/dwc/DWCPropRegs/2024/Utilization-Review/Index.htm