Pharmacy benefit management program

Notice: Texas Mutual's pharmacy benefit manager, Optum, has upgraded its platform. Optum will continue to provide the same excellent service. If you have any questions, contact Optum at the number below.

Texas Mutual Insurance Company partners with Optum to help ensure that injured workers get the prescriptions they need for their compensable on-the-job injuries.

If you prescribe medication for the treatment of injured workers, you should be familiar with DWC Rule 134.502.

If you need assistance from Optum, contact them at (800) 964-2531.

First Fill program

Injured workers can get their first prescription filled even if their employer hasn't yet filed a claim. The First Fill Program requires that injured workers present a First Fill form at a participating Optum pharmacy to get a seven-day supply for each covered prescription with a maximum of $500 per prescription. The form is valid only for the first fill and cannot be used if the first prescription fill is being requested more than 10 days after the injury occurred.

State adopts pharmacy closed formulary

The Texas Department of Insurance, Division of Workers' Compensation (DWC) has adopted a pharmacy closed formulary for claims occurring on or after September 1, 2011. The formulary is intended to facilitate drug-prescribing consistency between network and non-network claims. DWC has posted the entire list of "N" drugs as published by Official Disability Guidelines (ODG) in Appendix A on its website, free of charge.

Do electronic billing requirements apply to you?

Under Texas law, most pharmacies that dispense to workers' compensation patients in Texas must bill insurance carriers electronically.

For more information, contact Optum at or (800) 964-2531.

Your pharmacy may qualify for an exemption if it meets one of these conditions:

  • You are a small practice with 10 or fewer employees and workers' compensation accounts for less than 10% of your practice.
  • You can show that implementing electronic billing presents an unreasonable financial burden.

Even if you qualify for a waiver, you should consider billing electronically. It saves time, and it reduces paperwork and coding errors.