How to Fill Your Prescription Under Workers Compensation

 

Follow These Steps to Get the Prescription Drugs You Need for Your Workplace Injury or Occupational Disease

 

The right to medical treatment for your work injury is a critical workers compensation benefit. Unfortunately, it is often the most difficult to use, with insurance companies and third-party administrators such as Sedgwick and Gallagher Bassett delaying authorization.

 

Though doctor visits and diagnostic tests such as MRIs, X-rays, and CT scans are sometimes the subjects of litigation, prescription medication is the most common medical treatment delayed and denied by insurers.

 

I have seen the frustration and struggles that injured workers like you deal with to get prescription medications – even when you have proven your right to benefits and received a Workers Compensation Award Letter. Dealing with a work injury or occupational disease is stressful enough. Now you have to worry about paying for the medication you need to heal and get back to work. 

 

This article explains how to get the medication you need under workers comp. Your workers compensation payments should provide for your family, not the medicine prescribed by your workers comp doctor. 

 

Keep reading for more information. 

 

If you have questions about how workers comp works or want a top-rated Virginia work injury lawyer to fight for you, call me: (804) 251-1620 or (757) 810-5614. I’ve helped injured employees like you negotiate tens of millions of dollars in workers comp settlements – and I’m ready to help you. 

 

Contents hide
1 How to Fill Your Prescription Under Workers Compensation
1.1 Follow These Steps to Get the Prescription Drugs You Need for Your Workplace Injury or Occupational Disease
2 Do I Have to Pay Out-of-Pocket for Medications for My Work Injury? Your Right to Prescription Drugs under Workers Compensation
3 Will Workers Comp Pay for Brand-Name Medication, or Do I Have to Use a Generic Drug?
4 Common Medications Prescribed for Work-Related Injuries and Mental Health Conditions
5 How Will the Pharmacy Know that Workers Comp Should Pay for My Prescription?
6 Why am I Having Trouble Getting My Workers Comp Prescription Filled?
7 What are My Options if the Workers Comp Insurer Refuses to Pay for Medication?
8 Are Alternatives to Prescription Medication Covered under Workers Comp?
9 I Deal with the Insurance Company so You Don’t Have to

 

Do I Have to Pay Out-of-Pocket for Medications for My Work Injury? Your Right to Prescription Drugs under Workers Compensation

 

No, you do not have to pay out-of-pocket for prescription medication for your work-related injury.

 

The purpose of workers comp is to restore your health so you can return to some gainful employment. Full duty, if possible, light-duty if not.

 

Your employer must provide the treatment you need, free of charge. This care includes medications prescribed to control pain, depression, and other symptoms. Prescription drugs are an essential part of the healing process, often necessary for a successful recovery.

 

Will Workers Comp Pay for Brand-Name Medication, or Do I Have to Use a Generic Drug? 

 

Maybe.

 

Whether or not the insurer must pay for brand-name medication depends on your authorized treating physician’s opinion. 

 

We will start by discussing the difference between brand-name and generic drugs. 

 

Generic drugs are supposed to work the same way as brand-name drugs. They have the same active ingredient and come in the same dosage, strength, and administration (how you take the drugs). However, a generic drug may not be as effective for you. 

 

Workers comp insurers prefer generic medications to brand-name medications because they cost less. One study found that generic drugs typically cost about 75% less than the same brand-name drug.  

 

After years of lobbying, employers and insurers convinced the General Assembly to pass Code Section 65.2-603.1 in 2009. This statute, entitled Use of Therapeutically Equivalent Drug Products Required, directs pharmacists to fill a medication for a workers compensation claimant with the generic drug, not the brand-name medicine. 

 

However, certain exceptions exist. For example, the pharmacist may dispense the brand-name drug if:

 

  • A generic drug product does not exist;

 

  • The generic drug costs more than the prescribed name-brand drug product; or 

 

  • Your doctor states there is a medical reason why you need the name-brand drug. 

 

Your request for the name-brand drug is insufficient. If you and your doctor believe that name-brand medicine is more effective than the generic drug, ask your doctor to put that in writing. 

 

Common Medications Prescribed for Work-Related Injuries and Mental Health Conditions

 

Many orthopedic injuries – injuries to the back, neck, shoulder, and knee, to name a few – heal better with medication. The same is true of head injuries resulting in post-concussion syndrome. Prescription medicines can help control your symptoms so that you have a better quality of life.

 

The most common classes of medication prescribed for on-the-job injuries are:

 

  • Opioids: These medications provide pain relief for work injuries, but can also result in addiction. Opioids are the most expensive and prescribed type of drug in workers compensation.

 

 

  • Dermatological Medications (Compounds and Patches): These medications provide pain relief.

 

  • Antidepressants: Many injured workers benefit from antidepressant medication prescribed to improve mood and reduce nerve pain.

 

  • Anticonvulsants: These medications can help reduce pain from damaged nerves.

 

The chart below lists the brand and generic names of drugs often prescribed for work injuries, employment-related psychiatric illnesses such as PTSD, and heart disease suffered by police officers and firefighters.

BRAND NAME GENERIC NAME USE
Proventil, Ventolin Albuterol Asthma, Lung Conditions
Xanax Alprazolam Anti-Anxiety
Elavil, Endep Amitriptyline Antidepressant
Norvasc Amlodipine Hypertension
Abilify Aripripazole Antidepressant
Wellbutrin Bupropion Antidepressant
Buspar Buspirone Anti-Anxiety
Ativan Carazapam Anti-Anxiety
Tegretol Carbamazepine Anti-Seizure, Nerve Pain
Soma Carisoprodol Pain Relief
Celebrex Celecoxib Anti-Inflammatory
Keflex Cephalexin Antibiotic
Cipro Ciprofloxacin Antibiotic
Klonopin Clonozepam Anti-Anxiety
Plavix Clopidogel Anticoagulant
Flexeril Cyclobenzaprine Muscle Relaxer
Valium Diazepam Anti-Anxiety
Voltaren Diclofenac Pain Relief
Depakote Divalproex Anti-Seizure
Cymbalta Duloxetine Antidepressant, Pain
Lexapro Escitalopram Antidepressant
Prozac Fluoxetine Antidepressant
Lasix Furosemide Heart, Edema (Swelling)
Neurontin Gabapentin Nerve Pain, Anti-Seizure
Hysingla Hydrocodone Opiate Pain Reducer
Dilaudid Hydromorphone Opiate Pain Reducer
Plaquenil Hydroxychloroqui Connective Tissue Disease
Advil, Motrin Ibuprofen NSAID
Toradol Ketorolac Opiate
Keppra Levetiracetam Anti-Seizure
Xylocaine Lidocaine Numbing Agent
Mobic Meloxicam Anti-Inflammatory
Demerol Meperidine Opiate
Robaxin Methocarbamol Muscle Relaxer
Medrol methylprednisone Steroid Anti-Inflammatory
MS Contin Morphine opiate pain reducer
Aleve Naproxen NSAID
Oxycontin Oxycodone Opiate Pain Reducer
Paxil Paroxetine Antidepressant
Dilantin Phenytoin Anti-Seizure
Feldine Piroxicam NSAID
Deltasone Prednisone Steroid Anti-Inflammatory
Lyrica Pregabalin Neuropathic Pain
Darvon Propoxyphene Opiate Pain Reducer
Zoloft Sertraline Antidepressant
Imitrex Sumatriptan Migraines
Topamax Topiramate Migraines, Seizures
Ultram Tramadol Pain Medication
Effexor Venlafaxine Antidepressant
Coumadin Warfarin Blood Thinner

 

How Will the Pharmacy Know that Workers Comp Should Pay for My Prescription?

 

If you have an accepted claim – either through an Award Agreement form or a judicial opinion entered after a workers comp hearing – the claim adjuster should send you a prescription card.

 

Present the workers compensation prescription card to your pharmacy, and ask the pharmacist to keep the information on file for future refills.

 

If you need to fill a prescription but have not received a prescription card, give the pharmacist the adjuster’s contact information and the claim number.

 

Why am I Having Trouble Getting My Workers Comp Prescription Filled?

 

There are several reasons you may have difficulty getting your prescription filled.

 

First, the insurer does not have to pay for prescriptions if it has not accepted your claim. When an insurer feels that it has defenses to your workers comp claim, it often refuses to cover medical treatment.

 

Second, the insurer may be stalling to see if you press the issue. Medications are expensive. On average, medical costs make up more than half of the total cost of workers compensation claims – and medication makes up more than ten percent of the medical expenses. In some cases, such as those involving Complex Regional Pain Syndrome (CRPS), it can make up even more. If you’ve dealt with an insurance company before, you know there is a significant chance it will not act unless you force it.

 

Third, your pharmacy may not be used to dealing with workers compensation claims. This lack of familiarity could result in the pharmacist not knowing how to submit their bill for payment, or submitting it incorrectly. This administrative error could result in the insurer rejecting the charge.

 

What are My Options if the Workers Comp Insurer Refuses to Pay for Medication? 

 

You have options if the insurer won’t cover medicines prescribed for your work injuries. 

 

First, file a workers comp claim if you haven’t already. After you file, the Workers Compensation Commission will docket your case for hearing. If you win, the insurer will be liable for medication. I recommend this option if you don’t have an Award Letter. 

 

Second, fill your prescription using other means, if necessary. 

 

For example, you can use your private health insurance, Medicare, or Medicaid coverage to pay for medication if the insurer denies your claim. 

 

You can also use one of the specialty pharmacies that service injured workers and auto accident victims with pending claims – Alliance Meds, Injured Workers Pharmacy, WIRX Pharmacy, Summit Pharmacy, and Valuecare Pharmacy. These pharmacies provide prescriptions for your work injury whether or not your claim is accepted. They then seek reimbursement from the insurer. 

 

Another option is to ask the pharmacist to accept a Letter of Protection. This letter states that the pharmacist agrees you can defer payment until your claim resolves. You can also ask your pharmacist to call me. I’ve helped many medical providers get their bills paid through workers comp. 

 

Those of you hurt in a work-related motor vehicle accident may be able to use your auto insurance policy to pay for prescriptions, especially if you have Medical Payments coverage (MedPay).

 

No matter what option you choose, make sure you keep track of your receipts and all out-of-pocket payments. Then file a change in condition claim asking the Commission to order the employer and insurer to pay for your medication and reimburse all monies spent on the work injury medicines.

 

Are Alternatives to Prescription Medication Covered under Workers Comp?

 

Yes, workers compensation covers alternative treatments for pain – but only if your treating physician states the alternative medicine is reasonable, necessary, and related to your work injury.

 

Having spoken with thousands of injured workers, I understand that many of you do not like how prescription medication makes you feel – even if it reduces your pain and other symptoms. The side effects may outweigh the pain relief.

 

I also understand that you may want to try other types of treatment to relieve your pain while taking prescription medicines so that you can gradually decrease your dosage.

 

Your employer is responsible for providing palliative care for your work injury. Palliative care is a treatment that provides temporary relief and increased function.

 

Typical forms of palliative care for work injuries include:

 

 

I Deal with the Insurance Company so You Don’t Have to

 

The workers comp claim process is frustrating, confusing, and complicated – and that’s putting it nicely.

 

Don’t spend your time fighting the insurance carrier for medical care. Instead, call me: (804) 251-1620 or (757) 810-5614. I’ll take care of the paperwork and legal battles while you focus on healing.

Corey Pollard
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