If your claim is accepted and your authorized treating physician prescribes medication for you, but your pharmacist tells you that there is a problem, follow these steps
1. Have a copy of your claim acceptance letter with your claim number and name and address of your third-party administrator or insurer in hand when you go to the pharmacy.
2. Do not confuse things by giving your pharmacist your health insurance card. Instead, you want the workers’ compensation carrier billed.
3. If the pharmacist tells you that your prescription has been denied, pay for the medication so that you can get it started if it is essential that you start it right away. For example, it you just had surgery and need an antibiotic, don’t wait. Or, if you need pain medication right away, just get the medication, and then straighten out the problem. It can take a day or two to get medication problems resolved, so don’t drive yourself crazy by not getting the medication if you can afford it. Keep a copy of the receipt that shows what medication you paid for, and send it to your adjuster, requesting reimbursement.
4. Call your adjuster or fax or email the name of the medication, who prescribed it, and the name and phone number for your pharmacy. Don’t just leave a message or complain that you didn’t get your medication authorization. Make sure you give the adjuster information she can use to fix the problem.
5. If you have a nurse case manager assigned to you case, instead of calling the adjuster, you can call the nurse case manager. She is likely to be more familiar with what the doctor prescribed, and may be able to help you quicker. Again, give her your pharmacy phone number.
6. Expect delays if the medication ordered is an expensive proprietary formula, as the insurer may question why generic wasn’t prescribed, or whether other medications were tried first. Maybe your doctor can give you some samples to start if he knows that insurers usually drag their feet on authorizing this particular medication.
Unfortunately, I expect more problems in the future obtaining medication for injured workers. According to an recent article in Business Insurance, there is a growing trend among states to creating medical guidelines for doctors prescribing opioid pain medications to workers’ compensation claimants. Additionally, many insurers now use intermediary companies that involve another step in the authorization process, and thus, more delays.