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
Benzodiazepines, see
WAC 296-20-03014(4)
time limitations
Botulinum toxin X  
Buprenorphine oral products  
Buprenorphine (Butrans) transdermal system    
Compounded drug products  
Carisoprodol products   X
Direct-acting antivirals for hepatitis C  
Drug therapy for neuropathic pain (effective January 1, 2019) X      
Fentanyl transmucosal products    X
Fentanyl transdermal products (Duragesic ®)   X 
Hyaluronic acid/Viscosupplementation X  
Medical food or "co-pack" products       X
Post-exposure prophylaxis (PEP) X      
Propanolol for anxiety symptoms   X    
Opioids for non-cancer pain X  
time limitations
Tobacco cessation for surgical care   X 
Tramadol productsX   

Archived Drug Coverage policies

The following policies will be discontinued on December 31, 2018:

Antiepileptic drugs (AEDs) for neuropathic pain
Duloxetine for chronic musculoskeletal pain
Local anesthetics - Lidocaine patch (Lidoderm ®) and lidocaine / prilocaine cream (EMLA ®)


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