2019 FECA Circulars Archive

Attention: This circular has been superseded and is inactive.

Subject: Filling Non-maintenance Medications

Purpose: This circular is being issued to document the policies regarding filling non-maintenance medications for the treatment of work-related injuries or illnesses.

Background: Under the FECA, the Department of Labor's (DOL) Office of Workers' Compensation Programs (OWCP) may provide to an employee injured while in the performance of duty, the services, appliances, and supplies prescribed or recommended by a qualified physician, which OWCP considers "likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of the monthly compensation." See 5 U.S.C. 8103. The Act and its implementing regulations at 20 C.F.R. Part 10, Subpart I (20 C.F.R. 10.800) authorizes OWCP's FECA program to set limitations and require pre-authorization for medical services and supplies where deemed necessary.

In accordance with the discretion granted to DOL and delegated to OWCP, in May, 2017 OWCP's Division of Federal Employees' Compensation (DFEC) instituted a new policy for filling non-maintenance medications for work-related illnesses or injuries.

Actions: With respect to non-maintenance medications, the policy limits the dispensing of such medications to 30 day increments. Additionally, refills cannot be obtained until 75% of the prescription timeline has passed. Maintenance medications (such as those used to treat chronic conditions like high blood pressure and asthma) are not subject to these limitations.

Physicians seeking to have the 30 day/75% fill requirement waived for non-maintenance drugs should submit a written request directly to the responsible DFEC district office because there is no method of requesting an exception through the Web Bill Processing Portal. Waiver of the fill requirements for non-maintenance drugs will be authorized on an exception basis only based on approval of the OWCP Chief Medical Officer or his/her designee.

ANTONIO RIOS
Director for
Federal Employees' Compensation

Distribution: All DFEC Staff

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Attention: This circular has been superseded and is inactive.

Subject: Bill Pay - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment.

Background: Effective January 1, 2019, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobile INCREASED to 58.0 cents per mile by GSA. No restriction is made as to the number of miles that can be traveled. As in the past, determination has been made to apply the applicable rate to disabled FECA beneficiaries traveling to secure necessary medical examination and treatment.

Applicability: Appropriate National Office and District Office personnel.

Reference: Chapter 5-0204, Principles of Bill Adjudication, Part 5, Benefit Payments, Federal (FECA) Procedure Manual and 5 USC 8103.

Action: The Central Bill Pay (CBP) facility has updated their system to reflect the new rates. Since there is no action required at the District Office level, the rates are being provided for informational purposes only.

ANTONIO RIOS
Director for
Federal Employees' Compensation

Distribution: All DFEC Staff

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Attention: This circular has been superseded and is inactive.

Subject: Dual Benefits - FERS Cost of Living Adjustments

Background: Effective December 1, 2018, benefits issued by the Social Security Administration (SSA) will be increased by 2.8%. This requires the amount of the Federal Employees' Retirement System (FERS) Dual Benefits deduction to be increased by the same amount, to ensure the dollar-for-dollar offset remains current.

Applicability: Appropriate National Office and District Office personnel.

Action: This adjustment will be made from the National Office for all cases that were correctly entered into the iFECS Compensation program. The adjustment will be effective with the periodic roll cycle beginning December 09, 2018. There will be no adjustment or overpayment declared for the period of December 1, 2018 through December 8, 2018.

ANTONIO RIOS
Director for
Federal Employees' Compensation

Distribution: All DFEC Staff

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Attention: This circular has been superseded and is inactive.

SUBJECT: Current Interest Rates for Prompt Payment Bills and Debt Collection

The interest rate to be assessed for the prompt payment bills is 2.625 percent for the period of July 1, 2019 through December 31, 2019. This new rate has been updated in the Central Bill Payment system tables. The rate was changed from 3.625 percent because there was a difference in the Current Value of Funds (CVF) interest rate of more than two percent.

The rate for assessing interest charges on debts due the government remains unchanged again this year. The interest rate for assessing interest charges on debts due the government is 1.0 percent for the period of January 1, 2019 through December 31, 2019. This rate remains unchanged in the iFECS system tables.

Attached to this Circular is an updated listing of both the Prompt Payment and Debt Management interest rates from January 1, 1985 through the current date.

ANTONIO RIOS
Director for
Federal Employees' Compensation

Attachment: Prompt Payment Interest Rates
Debt Management Interest Rates

Distribution: All DFEC Staff

ATTACHMENT TO FECA CIRCULAR NO. 19-08

ATTACHMENT TO FECA CIRCULAR NO. 19-08

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Attention: This circular has been superseded and is inactive.

SUBJECT: Prescription and non-prescription or over-the-counter (OTC) drugs

PURPOSE: To provide notification of new DFEC policy with respect to payment for non-prescription or over-the-counter (OTC) drugs instead of certain prescription drugs.

REFERENCES: 5 U.S.C. § 8103; 5 U.S.C. § 8124 (a)(2); 5 U.S.C. § 8128; 5 U.S.C. § 8145; 5 U.S.C § 8149; 20 C.F.R. 10.800-826; FECA Procedure Manual 3-400-3-a. FECA Bulletins 17-01 and 17-03; FECA Circulars 18-05 and 19-05.

BACKGROUND:

Under the Federal Employees' Compensation Act (FECA), the Department of Labor's (DOL) Office of Workers' Compensation Programs (OWCP) may provide to an employee injured while in the performance of duty, the services, appliances, and supplies prescribed or recommended by a qualified physician, which OWCP considers "likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of the monthly compensation." See 5 U.S.C. 8103. The Act and its implementing regulations at 20 C.F.R. Part 10, Subpart I (20 C.F.R. 10.800) authorize OWCP's FECA program to set limitations and require pre-authorization for medical services and supplies where deemed necessary, including the issuance of an exception-based policy.

FECA Bulletin 17-01 (issued October 14, 2016) implemented new controls for the authorization of compounded medications.

FECA Bulletin 17-03 (March 22, 2017) implemented a new policy that herbal supplements would only be authorized on an exception basis.

FECA Circular 18-05 (issued February 14, 2018) implemented an exception-based policy pertaining to convenience kits and certain other combination medications. Authorization and payment for specified National Drug Codes (NDCs) now automatically denies when:
1. OWCP's Division of Federal Employees' Compensation (DFEC) has determined that the items in the kit/medication can typically be obtained separately and/or at a lower cost and there is a reasonable commercially available alternative or substitute; or
2. The primary use is for a condition not normally caused by a workers' compensation injury.
For FECA Circular 18-05, DFEC published on its website an initial list of 49 NDCs that were set to deny based on these criteria. Since publication, DFEC has continued to use data analytics to identify other NDCs that fit these criteria and add them to the list.

FECA Circular 19-05 (issued February 22, 2019) implemented an exception-based policy pertaining to the dispensing of specific prescription medical devices (that are billed with NDCs), which has emerged as a possible substitute for the prior practice of compounding and prescription medication kits and combination medications.

DFEC has identified a similar trend in the dispensing of medications via prescription-only when nonprescription or over-the-counter (OTC) drugs are commercially available.

When originally enacted, the Federal Food, Drug, and Cosmetic Act of 1938 did not make a distinction between prescription and OTC drugs. In 1951 the Durham-Humphrey amendments to the act set up criteria to differentiate between these two classifications of drugs. Prescription drugs were recognized as any drug that cannot be used safely without professional supervision and therefore can only be dispensed only by prescription. OTC drugs were recognized as any drugs which are safe and effective for use by the general public without seeking treatment by a health professional. A separate process was later implemented by the U.S. Food and Drug Administration (FDA) which provided a path for the reclassification of drugs from prescription to OTC status which is referred to as an "Rx to OTC switch".¹

Non-prescription or OTC drugs are generally less expensive than prescription alternatives according to the FDA, and in July 2018, the FDA released draft guidance detailing innovative approaches that could lead to the approval of a wider range of non-prescription drug products. (U. S. Food and Drug Administration Saving Money On Prescription Drugs and Innovative Approaches for Nonprescription Drug Products)

Like convenience kits and prescription medical devices, the cost of certain prescription drugs can be extremely high and, in some instances, there may be safe and commercially available alternative OTC drugs at a lower cost.

For example, Omeprazole/Sodium Bicarbonate 20/1100 mg capsules are available both by prescription and OTC. The OTC version of this drug is the same dosage while being commercially available at a substantially lower cost.

In accordance with the discretion granted to DOL and delegated to OWCP, DFEC is instituting a new exception-based policy pertaining to payment of certain drugs that fit the description above.

ACTION:

1. Authorization and payment will automatically deny when DFEC has determined that the prescribed drug(s) has a medically reasonable alternative that is available OTC at a lower cost.
   
2. For ease of use and ready reference, DFEC will use the same Denial List that it uses for updates based on Circular 18-05.
   
3. DFEC will continuously and regularly review and evaluate drugs that fit this criteria in accordance with the above policy and set the corresponding NDC to deny. As this evaluation process progresses, additional non-payable drugs will be added to the denial list. The list can be found in its entirety, with effective dates, on DFEC's website.
   

   Prescription Drugs With OTC Alternatives Being Added to the NDC Denial List with the Publication of this Circular:

   NDC	Drug Name
   71399242003	Omeprazole/Sodium Bicarbonate 20/1100 mg capsule
   13107011530	Omeprazole-Sodium Bicarbonate Oral Capsule 20-1100 MG
   27241002931	Omeprazole-Sodium Bicarbonate Oral Packet 20-1680 MG
   27241002962	Omeprazole-Sodium Bicarbonate Oral Packet 20-1680 MG
   49884026811	Omeprazole-Sodium Bicarbonate Oral Packet 20-1680 MG
   49884026852	Omeprazole-Sodium Bicarbonate Oral Packet 20-1680 MG
   55111036330	Omeprazole-Sodium Bicarbonate Oral Capsule 20-1100 MG
   68682099030	Omeprazole-Sodium Bicarbonate Oral Packet 20-1680 MG
   69367019530	Omeprazole-Sodium Bicarbonate Oral Capsule 20-1100 MG
   69665011530	OmePPi Oral Capsule 20-1100 MG
   16714050801	Omeprazole-Sodium Bicarbonate Oral Capsule 20-1100 MG
   68382050106	Omeprazole-Sodium Bicarbonate Oral Capsule 20-1100 MG
   69097091302	Omeprazole-Sodium Bicarbonate Oral Capsule 20-1100 MG
   68012005230	Zegerid Oral Packet 20-1680 MG
   68012010230	Zegerid Oral Capsule 20-1100 MG
   60505082901	Fluticasone propionate nasal spray
   65162025310	Ranitidine HCl 150 mg tablet

   
   
4. Providers are expected to review this list prior to dispensing to determine if the drugs will be covered for payment. DFEC will also place notice regarding this new policy on the DFEC Web Bill Processing website.
   
5. Claimants whose pharmacy will not dispense a specific drug as it is not covered for payment based on the above criteria are expected to discuss with their physician the available OTC options. Reimbursement for expenses associated with these OTC drug options can be claimed by use of form OWCP-915, Claim for Medical Reimbursement.

Exception Basis Note: DFEC policy on considering exceptions for specified drugs as described in this Circular and on the list will follow that set forth in FECA Bulletin 17-03. This means that the prescription drugs on DFEC's denial list can only be approved on a District Director exception basis when a claimant's treating physician acquires pre-authorization by submitting rationalized medical evidence to the claims examiner that explains why the authorization of the prescription drug is medically necessary and cost effective, fully explaining why the commercially available alternative is not suitable for this condition for this particular claimant. In the event that the exception is denied, a formal decision will be issued to the claimant upon request.

ANTONIO A. RIOS
Director for Federal Employees' Compensation

Distribution: All DFEC Staff, OWCP Branch of Medical Standards and Rehabilitation

¹See generally Federal Food, Drug, and Cosmetic Act Amendments (Durham-Humphrey amendments), Pub.L.No.82-215, 65 Stat. 648 (1951); 21 U.S.C. Chapter 9 § 301 et seq

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