Medication Physician Review Instructions Rev iew the claim file. In the Analysis section, indicate the medical records review ed, specifically referencing important infor mation from those records. Pr ovide an opinion based upon the information identified in the "Analysis" section. Explain your opinion, w ithin a reasonable degree of medical certainty, referencing, w here appropr iate, Ohio State Medical Board Guidelines, Official Disability Guidelines and the standard of care for the community. Relate this infor mation to the specifics of this case, i.e., allow ed conditions and/or focus of treatment. Claim number Date of injury MCO name Injured w orker's name Allow ed conditions / / Fax number The attached claim is referred to you on by ( ) Recom mend medication reim bursem ent denied Therapeutic class code Therapeutic class code description Drug nam e, strength Recom mend medication reim bursem ent approved Comments BWC-3922 ( Rev. Jan. 15, 2015) MEDCO-22 American LegalNet, Inc. www.FormsWorkFlow.com Medication Physician Review 1. For each therapeutic drug class, please answer the following: a. Is the class reasonably related to the treatment of the allowed conditions? b. Is the class reasonably necessary for the treatment of the allowed conditions? c. Is the cost of the class medically reasonable for the treatment of the allowed conditions, i.e. is the use of this class appropriate resource utilization? 2. For each specific drug, including its prescribed dosage and duration, please answer the following: a. Is the drug, as prescribed, reasonably related to the treatment of the allowed conditions? b. Is the drug, as prescribed, reasonably necessary for the treatment of the allowed conditions? c. Is the cost of the drug, as prescribed, medically reasonable, for the treatment of the allowed conditions, i.e. is the drug, as prescribed, appropriate resource utilization? 3. With the understanding that all drugs are potentially harmful, please answer the following: a. Does the potential harm of any of the prescribed drugs in the amounts currently prescribed substantially outweigh the expected medical benefit of the drug? b. If yes, is there a medically supported alternative medication for treatment of the allowed condition? c. Is the combination of currently prescribed drugs in compliance with best practices? Physician's narrative Analysis Physician's name (typed) Physician's signature Date Time spent / / BWC-3922 ( Rev. Jan. 15, 2015) MEDCO-22 American LegalNet, Inc. www.FormsWorkFlow.com