Newly injured workers:
If you are injured at work, you may need to have new prescriptions filled to treat your injury and/or occupational disease. Ohio law provides guidelines for paying pharmacies for prescriptions if you work for a state-fund or self-insured employer. BWC administers workers’ compensation programs for state-fund employers and self-insured employers administer their own programs.
The information below answers your questions about obtaining prescriptions for your new workers’ compensation injury and/or occupational disease.
When you have a work-related injury, it is important that you determine if you work for a state-fund or a self-insuring employer. If you don’t know, ask your union representative or your human resources department.
The process for obtaining prescription medications varies depending upon if your employer is self-insured or state fund. Self-insuring companies administer their own workers’ compensation programs, and the Ohio Bureau of Workers’ Compensation (BWC) administers state-fund employers’ programs.
BWC or your self-insuring employer will assist you in obtaining appropriate prescription medications.
BWC and the pharmacy benefits manager try to make it as easy as possible for you to obtain your prescription medication(s) for work-related claims.
To obtain prescription medication(s), follow these basic steps:
- Explain to the pharmacy’s employees that your prescription is for a workers’ compensation claim.
- If you already have a claim number, tell the pharmacy your number. If you do not have a claim number, you could be asked to provide your Social Security number and the date of your injury and/or occupational disease.
- Depending upon the pharmacy, individual pharmacies may require a claim number prior to dispensing medication. If the pharmacy requires a claim number, you have the option of either obtaining the claim number through BWC’s Web site, ohiobwc.com, or by filing your claim with your local customer service office in person, via the telephone or with your managed care organization. If necessary, you also may have the prescription filled at a different pharmacy.
- If you have a claim number, but BWC has not yet allowed your claim, the pharmacy can accept assignment. This means you do not have to pay for the prescription, and the pharmacy will not charge you for the prescription. However, if the pharmacy requires payment, inform the pharmacy it’s a workers’ compensation claim, and it should only charge BWC’s prescription reimbursable rate. Ask your pharmacy if it is charging BWC’s reimbursable rate because BWC will not reimburse you the difference if the pharmacy charges a higher rate.
- Pharmacies electronically submit their prescription bills to BWC’s pharmacy benefits manager, ACS State Healthcare. ACS State Healthcare pays pharmacies the amount BWC will reimburse. If you paid for your prescription, once BWC allows your claim, you can apply for reimbursement. . To ensure speedy reimbursement, BWC needs your correct mailing address on file.
- If BWC denies your claim, you will be liable for the cost of the prescription.
Accepting assignment means the pharmacy will fill the prescription and not charge the injured worker. Some independent pharmacies and individual chain stores will accept assignment before BWC allows a claim or establishes a claim number. The pharmacy usually does this on an individual basis where it has an established working relationship with the injured worker. There is no definitive list of pharmacies that will provide this service.
These tips about generic prescriptions apply if you work for a state-fund employer.
• If a generic drug is available, BWC can only reimburse at the reimbursable rate for that generic drug. BWC rules mandate payment at the reimbursable rate for generic drugs when a generic drug is available for a name-brand prescription.
• If a generic drug is not available, BWC will pay for a name-brand prescription.
• If a generic is available, you may choose a name-brand prescription, but you will need to pay for the difference in price from the generic to the name brand. BWC will not reimburse you for the difference.
• For the majority of workplace diseases and injuries, there are generic drugs available that are effective in treating these conditions.
• The health-care industry accepts generics as best practice.
You may be familiar with generic and brand-name drugs from your company’s health-care plan. For example, the national research authority on generic drugs is the U.S. Food and Drug Administration’s (FDA) Center for Drug Evaluation and Research. The FDA writes in its consumer education newsletter and press release:
“When a brand-name drug’s patent protection expires, generic versions of the drug can be approved for sale. The generic version works like the brand-name drug in dosage, strength, performance and use, and must meet the same quality and safety standards. All generic drugs must be reviewed and approved by the FDA.”
The FDA reports: “All generic drugs are put through a rigorous, multi-step review process that includes a review of scientific data on the generic drug’s ingredients and performance. The FDA also conducts periodic inspections of the manufacturing plants, and monitors drug quality – even after the generic drug has been approved. “
According to the FDA, pharmacies fill an estimated half of all prescriptions in the United States with generic drugs. They carry all the medicinal qualities (and side effects) of their brand counterparts, but generics have one additional benefit: lower cost.
“FDA-approved generic drugs are bioequivalent and therapeutically equivalent to their brand-name counterparts,” says Gary Buehler, director of FDA’s Office of Generic Drugs.” People can use them with total confidence.”
The FDA has information on generic drugs on its Web site at www.fda.gov/cder/ogd/index.htm, or you may contact your physician, pharmacist or call 1-888-INFO-FDA. If you have questions about a drug’s effectiveness or possible side effects, discuss them with your physician and/or pharmacist. Your physician will make an appropriate recommendation.
For more information about BWC’s prescription program, talk with your claims service specialist. You may also log on to BWC’s Web site at ohiobwc.com, or call 1-800-OHIOBWC, and listen to the options.
Self-insuring employers administer their own workers’ compensation program. If you work for a self-insured company, report your injury to your employer. If possible, let your employer know you have a prescription for a work-related injury that you need filled. Your employer may then suggest a pharmacy that has a working relationship with the company.
In addition, ask your employer if there are area pharmacies that have point-of-service contracts with your employer’s pharmacy benefit manager. Find out which pharmacies are in your employer’s network or contract. If you use a network pharmacy, the pharmacy should bill your employer for the prescription. If possible, you should give the pharmacy your Social Security number, and/or claim number and/or third-party biller number.
Most chain pharmacies have a relationship with a third-party biller that pays pharmacies up front for prescriptions. The third party then identifies the self-insured employer and submits a bill to the employer.
For your information, BWC Rule 4123-7-23 Payment for Outpatient Medications is effective July 2006 for self-insuring employers.
Per this Rule, self-insuring employers now may reimburse at BWC’s rate or the employer’s negotiated rate with the pharmacy provider. Self-insuring employers must pay requests for reimbursement within 30 days of receiving the receipt from the injured worker.
If the self-insuring employer has point-of-service adjudication, the employer can then reimburse at the reimbursable rate for generic drugs when a generic is available. If a worker refuses a generic drug, the worker is responsible for the difference in cost between the generic and the brand-name drug, and the employer will not reimburse the worker. Check with your union representative or employer to see if your employer has a pharmacy benefits manager.
For additional prescription information, talk with your union representative or your employer. You may also contact BWC’s self-insured department at 1-800-OHIOBWC, and listen to the options.
To ensure you are taking the proper medications for your injury/or occupational disease, BWC or your self-insuring employer may request a drug utilization review. Below are the steps BWC and/or your employer should follow for this review.
• Inform you and your treating health-care provider of the planned review. Request clarification and justification from your provider in writing with copies to the claim’s parties for the drugs you are taking.
• Obtain a physician review and include any documentation from your treating provider. A physician review is an independent review and the physician of record, treating physician or the prescribing physician does not do it.
• You and your treating provider should receive a decision about the medication(s) appropriateness.
• For state-fund claims, an injured worker may file a motion to BWC’s allowance or denial letter. BWC may receive a motion may at any time and when it does, BWC determines if a new file review is necessary. The bureau then issues a BWC order with a decision to allow or deny the drug(s). The parties have 14 days to respond to this order, and if they disagree with the decision, BWC refers it to the IC.
• For self-insured claims, if the independent physician reviewer’s report indicates the drug treatment is not medically necessary or appropriate for the allowed conditions in the claim, the self-insuring employer may terminate reimbursement for the medication(s) effective as of the date of receipt of the independent physician reviewer’s report. The self-insuring employer should then notify all parties to the claim, including the prescribing health-care provider, of its intent to terminate reimbursement for the medication(s). This notification shall inform the injured worker of his or her right to request a hearing before the IC.
• The notification must include the injured worker’s right to appeal the decision to the IC for a hearing.
If you have general questions about prescriptions, you may contact BWC’s stakeholder relations regional representatives Janet Wilks at (614) 466-4722 or Kevin Quinn at (330) 430-1985.
