How Do I Get My Medicine Through Workers' Comp?

Getting Prescriptions Through Workers' Compensation

The method of getting prescriptions filled has become a complicated and lengthy process since the days of a doctor using a prescription pad and providing the prescription to the drug store. It now involves portals, forms, dashboards, nurse case managers, formularies, vendors, adjusters, authorizations and Orders of the Chair.

The current Workers’ Compensation Board process follows a Drug Formulary that recently went into effect. The drug formulary is a list of medications and dosages that can be prescribed for specific ailments without the need for preauthorization. Should your medical provider feel that one of the medications on the formulary is an appropriate treatment, a simple transmission to the pharmacy should suffice to get the medication filled. However, it is rarely this easy.

Pharmacies are not so quick to fill prescriptions for fear of not being paid by the insurance company. The pharmacies and insurance companies use an intermediary to communicate about the authorization for the medication. This intermediary is called a Pharmacy Benefits Manager or PBM. It is also often referred to as the vendor. An injured worker is generally advised of the PBM the insurance company uses in a packet at the outset of the claim. In some instances, the injured worker is given a pharmacy benefits card, which shows the injured workers’ information, as well as the vendors.

If the medical provider feels that the medication does not follow the formulary, the provider must then request authorization directly from the insurance carrier. The Workers’ Compensation Board has created a process for such requests. This process involves an online portal, which your provider must be registered to request medications. Once the request is made, it can be viewed on the portal’s dashboard and form (DF-L1) is generated, which is electronically transmitted to the insurance company for review and approval.

The insurance company has four (4) calendar days to respond to this request, usually handled by a nurse case manager. This is called a level one review. Pharmacies also have access to this portal and can review the status of the request. If the carrier denies the request or only submits a partial approval, the prescriber may request review of the denial or partial approval within 10 days. This is the level two review where the provider asks the Carrier to escalate the request. If this request is denied, it is escalated to level three review, where the Board then makes the final ruling.

In practice, we find that providers, pharmacies, and carriers are not following the procedure laid out by the Board. Some providers are not using the portal to make requests for medications outside the formulary. Some pharmacies are not honoring an authorization that was granted without again obtaining clearance from the vendor. The vendor will not authorize the pharmacy to dispense the medication without a communication from the carrier. So a process, which previously may have been resolved within a few hours, is now taking days with multiple levels of authorization needed.

Additionally, the process is not transparent. Injured workers and their representatives do not have access to the portal. Although the Workers’ Compensation Law has penalties in place for late compensation payments, there is no penalty for late or delayed dispensing of prescriptions. While it is true that the insurance carrier has four days to respond to an authorization request or the Board will issue an order of the chair authorizing the medication, pharmacies still may refuse to see this decision as authority and may not fill the medication.

Currently, the best practice to get a prescription filled quickly is to make sure the provider thoroughly documents the need for the medication and files a report outlining such need. The provider also needs to go through the portal to request the medication. The injured worker, together with his or her representative, must then hound the insurance company to take action.

Having Difficulties Getting Prescription Drugs Covered By Workers' Compensation? Get a Free Consultation with a Workers' Compensation Lawyer

At MCV Law, we encourage our clients to follow through with the treatment prescribed by their doctor and proactively pursue the course that will assist with their recovery and quality of life. Our goal is to help our clients get their lives back.

Should you need help with your claim, please contact us.