Overview
The Washington State Department of Labor & Industries (L&I) administers workers compensation benefits for employees injured on the job. A key component of those benefits is access to prescription medication through the L&I Outpatient Formulary. The formulary is a curated list of drugs that have been evaluated for safety, efficacy, and costeffectiveness for the treatment of occupational injuries and illnesses.
Because L&I covers a wide range of industriesfrom construction to health carethe formulary must balance the specific therapeutic needs of injured workers with the States responsibility to protect public funds. By using a standardized formulary, medical providers can ensure that workers receive appropriate medication while minimizing unnecessary expenses.
Whats Covered?
The formulary is organized into therapeutic categories. Below is a snapshot of the major groups and typical examples of covered agents. The list is not exhaustive; many additional drugs are approved within each class.
| Therapeutic Category | Representative Drugs | Typical Use in Workers Compensation |
|---|---|---|
| Analgesics NonOpioid | Acetaminophen, Ibuprofen, Naproxen, Celecoxib | Pain relief for mildtomoderate musculoskeletal injuries. |
| Analgesics Opioid | Hydrocodone/acetaminophen, Oxycodone, Tramadol | Shortterm management of severe pain when nonopioid options fail. |
| Muscle Relaxants | Carisoprodol, Cyclobenzaprine, Methocarbamol | Spasm reduction after softtissue injury. |
| AntiInflammatories (Topical) | Diclofenac gel, Capsaicin cream | Localized pain and inflammation. |
| Antidepressants (Neuropathic Pain) | Amitriptyline, Duloxetine, Venlafaxine | Chronic pain syndromes and posttraumatic stress. |
| Anticonvulsants (Neuropathic Pain) | Gabapentin, Pregabalin | Peripheral nerve injuries, complex regional pain syndrome. |
| Antibiotics | Amoxicillin, Cephalexin, Doxycycline | Infection prophylaxis or treatment after wound exposure. |
| Vaccines | Influenza, Hepatitis B, Tdap | Occupational health requirements for certain job classifications. |
| Emergency Medications | Epinephrine autoinjector, Albuterol inhaler | Acute allergic reactions or asthma exacerbations on site. |
| Specialty Drugs | Insulin analogs, Biologic agents (e.g., Adalimumab) | Diabetes management or autoimmune conditions when medically necessary. |
*The formulary is subject to periodic review. Drugs not listed may be approved on a casebycase basis if a provider can document medical necessity.
How to Use the Outpatient Formulary
Medical providers, workers, and employers follow a simple, threestep process to obtain medications covered by the formulary.
1. Confirm Eligibility
- Ensure the injured worker has an active L&I claim.
- Verify that the medication is being prescribed for a condition related to the occupational injury.
- Check that the prescribing provider is authorized under L&I rules (e.g., a licensed physician, podiatrist, or certified nurse practitioner).
2. Select a FormularyPreferred Drug
- Consult the most recent L&I Formulary List available on the L&I website.
- If a preferred medication is unsuitable, document the clinical rationale for an alternative and submit a Formulary Exception Request.
- Pharmacies must be enrolled in the L&I Pharmacy Network to dispense covered drugs directly to the worker.
3. Submit the Prescription and Billing
- The provider sends the prescription to a participating pharmacy using the standard electronic prescription (eRx) format.
- Pharmacy submits the claim using L&Is electronic billing portal (eClaims). The claim must include the workers claim number and the specific diagnosis code.
- L&I reviews the claim for formulary compliance; approved claims are paid directly to the pharmacy.
If a claim is denied, the provider can appeal with additional clinical documentation. Denials are typically based on formulary noncompliance, missing claim data, or questions about medical necessity.
Formulary Updates and Changes
The L&I formulary is not static. Updates occur at least twice per year, coinciding with the fiscal calendar. Changes may include:
- Adding newly approved drugs that demonstrate superior efficacy or safety.
- Removing drugs that have become costineffective or have been superseded by generics.
- Reclassifying drugs to different therapeutic tiers, affecting copay requirements for the worker.
All updates are posted on the L&I website with a downloadable PDF and a machinereadable XML file for integration with electronic health record (EHR) systems. Providers are encouraged to subscribe to the L&I Formulary Alerts mailing list to receive realtime notifications.
Resources for Workers and Providers
Below are key tools and contacts to help navigate the outpatient formulary.
- Formulary Lookup Tool: lni.wa.gov/formulary-search Search by drug name, class, or indication.
- Provider Portal: Secure login for claim submission, formulary exception requests, and audit reports.
- Pharmacy Network List: PDF directory of participating pharmacies throughout Washington State.
- Help Desk: Phone(877)2472455 (MondayFriday, 8am5pm PT) for claim questions.
- Training Webinars: Quarterly live sessions covering formulary updates, claim best practices, and case studies.
For additional assistance, consult the L&I Outpatient Services Overview, which provides a comprehensive guide to medical benefits, documentation requirements, and the appeals process.
