White Paper

Prior Authorization and High Dollar Rejections Guidebook: 2021 Edition

This guidebook provides claims professionals with easy access to information regarding indications, generic availability, and possible alternatives for most commonly prescribed medications in WC.
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White Paper Summary

This guide provides information on some of the most commonly prescribed medications in workers’ compensation. The intent is to provide a resource for claims professionals that allows easy access to information regarding indications, generic availability, and possible alternatives.

The claims professional can use this information when contacting the prescriber to determine if drugs on the list of alternatives have been tried. If the prescriber has attempted at least one of the other medications, the claims professional can feel more confident in approving the medication because the decision was supported with clinical evidence. If none of the alternative medications have been tried, the prescriber should be asked to consider trying one of the listed alternatives prior to prescribing the rejected medication.

Medications are listed alphabetically by generic name with the brand version beneath. This is modified from the industry standard of listing the brand version first to better reflect that the majority of drugs dispensed are now generic. The medication list, potential off-label uses, and possible alternatives are not exhaustive. Some drugs are listed as a One Drug Review candidate. This recommendation may change upon further review of an individual medication regimen.

The myMatrixx clinical team is available to answer questions related to a patient’s medication regimen. In some instances, a recommendation may be made to conduct a One Drug Review or a
more comprehensive Clinical and Safety Evaluation (CASE Rx)SM. Both of these products feature outreach to the prescriber to discuss the use of alternative medications and they may incur a
charge.

This guide is not intended and should not be used or relied upon for the purposes of prescribing or using a product. It is solely for reference purposes. The trademarks and other product names listed in this guide are the property of their respective companies.

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To learn more about myMatrixx, please visit their website.

myMatrixx® is a pharmacy benefit management company dedicated to workers’ compensation and uniquely able to deliver customized solutions and high touch customer service. For more information, visit myMatrixx.com.

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