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[Letterhead]
Tennessee Workers’ Compensation Drug Formulary
Patient Notification Letter
[DATE]
[PATIENT’S NAME]
[ADDRESS]
[STATE FILE NUMBER] [CLAIM NUMBER]
You are receiving this letter because you are being prescribed medications that could be affected by
new rules adopted by the Tennessee Bureau of Workers’ Compensation. We have attached a list of
drugs that you may be taking that will be affected.
Drug formulary rules require prescribers and pharmacies to obtain prior approval for certain
medications before they may be paid for by workers’ compensation.
Please be advised that this is not a complete list; other drugs that your doctor prescribes may be
affected as well. Please talk to your doctor at your next office visit if you are unsure whether you are
currently being prescribed medications that will be affected by these rules or whether discontinuation,
substitution or weaning of these medications may be appropriate for your care.
If your prescriber feels that the medications are medically necessary, and there is no satisfactory
substitute, they should request prior approval from your insurance carrier with enough time to allow for
review so that you do not have to wait to receive the prescribed medications.
It is important to know when these new rules will affect your claim:
Certain medications that were prescribed and dispensed for the first time under your claim after
January 1, 2016 will require prior approval starting on August 28, 2016.
Refills of affected medications that have been previously prescribed under your claim before
January 1, 2016 will require prior approval starting on February 28, 2017.
Please take this letter with you to your next appointment with your prescribing doctor and discuss your
medications. For more information about the drug formulary, please visit the Bureau’s website at:
http://www.tn.gov/workforce/section/injuries-at-work
or: http://www.tn.gov/workforce/article/wc-drug-formulary.