State Compliance
Voluntary/Informal Pharmacy Network
Pursuant to Texas Voluntary/Informal Pharmacy Network notification requirements – Texas Labor Code 408.0281(d) – this website contains information pertaining to the clients (carriers, third-party administrators and self-insured employers) who have contractual arrangements to access the Tmesys pharmacy network for the provision of pharmacy services at rates inconsistent with the Texas workers’ compensation pharmacy fee guidelines.
Pharmacy transactions processed through the Tmesys network are submitted directly to Tmesys and are paid directly by Tmesys to the provider at the specific rates established in the contract between Tmesys and the provider. Tmesys does not sell, lease, transfer or convey its specific contractual fee arrangement rates with network providers to any other entity.
As a pharmacy provider within the Tmesys Texas network, initial notification of this web address and associated information would have been provided to you, and revised communications and updates will be sent on an as needed basis as required by the law. Tmesys will update required compliance information posted on this website, and we urge you to refer to this information frequently. Should you have any additional questions concerning this information, please contact us at:
TMESYS
4502 Woodland Corporate Blvd. Suite 105
Tampa, FL 33614
800.964.2531
For additional information regarding entities that are contracted with, or have access to, the Tmesys pharmacy network, please click on the following Excel spreadsheet link:
Access List
For additional information regarding Tmesys operation as a Voluntary/Informal Pharmacy Network in Texas, including more comprehensive information on our network registration, click here to view the Texas network reporting site.
Closed Formulary
On December 3, 2010, the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) adopted rules establishing a “closed formulary” for pharmacy. These rules were adopted pursuant to an earlier legislative mandate and can be found in Texas Administrative Code (TAC) Title 28, §134.500 et seq.
The closed formulary includes all available FDA-approved prescription and non-prescription drugs prescribed and dispensed for outpatient use. In contrast, the closed formulary excludes the following:
- Drugs identified with a status of "N" in the most recent edition of the Official Disability Guidelines (ODG) Treatment in Workers' Comp/Appendix A, ODG Workers' Compensation Drug Formulary, and subsequent updates
- Any compound that contains a drug identified with a status of "N" in the most recent edition of the ODG Treatment in Workers' Comp/Appendix A, ODG Workers' Compensation Drug Formulary, and subsequent updates
- Any investigational or experimental drug for which there is early or developing scientific or clinical evidence demonstrating potential efficacy of the treatment, but which has yet to be broadly accepted as prevailing standard of care, as defined in Texas Labor Code (TLC) §413.014(a)
The effective dates for implementation of the closed formulary are bifurcated into “new” versus “legacy” claims. New claims are those with a date of injury on or after September 1, 2011, while legacy claims are those with a date of injury before September 1, 2011.
New claims are subject to the closed formulary requirements as of September 1, 2011. This means that for new claims, drugs prescribed and dispensed on or after September 1, 2011 – and excluded from the closed formulary – must be preauthorized. Preauthorization, as the term is used in Texas, means prospective utilization review (UR) and can only be performed by entities officially registered/certified with the state. Drugs not requiring preauthorization are still subject to retrospective review for medical necessity.
Legacy claims will not be subject to the closed formulary requirements until September 1, 2013; therefore, drugs dispensed for legacy claims prior to September 1, 2013 do not require preauthorization (except for investigational and experimental drugs), but they are still subject to retrospective review of medical necessity and reasonableness of health care.
Additional Documentation: