Rx Refills: A 60-Second Seminar in Workers’ Compensation Claims Handling

Often fraught with difficulty even in one’s personal affairs, the refilling of a medical prescription in a workers’ compensation case is sometimes a gargantuan endeavor! This is true even though prescription medicines and medical devices are covered benefits under a workers’ compensation claim and are often vital components in the treatment of an industrial injury.  When Utilization Review authorizes medicine, the authorization is an acknowledgment that the prescribed medication is required to cure and relieve from the effects of the industrial injury. However, thirty days later when the pharmacy processes a refill, the medication is suddenly denied because an updated UR authorization is deemed to be needed.

The procedure that usually occurs following the denial of a refill is rather cumbersome. The injured worker must contact and inform the primary treating physician of the denial. The PTP then fills out and submits an RFA to the claim administrator, who then forwards it to UR. Five workdays later UR approves the refill but leaves it is up to the injured worker to contact the pharmacy to request the prescription again be processed. Hopefully, the medication is still in stock.  Otherwise, it may take an additional two days for the pharmacy to obtain it.  Only then can the prescription be filled.  Meanwhile, as many as 14 calendar days may have passed by.

Let’s stop for a moment and analyze what just happened.  In this scenario everyone initially agreed the medication was necessary to treat the industrial injury.  Both the PTP and UR originally approved it, but when a refill was attempted, it was denied because a new UR authorization was thought to be needed.  Consequently, the injured worker now must wait at least two weeks without medication, a delay which can be troubling to the worker, at a minimum. Unfortunately, this scenario occurs with alarming regularity. If you have doubts, just speak to any pharmacist. They will tell you distressing stories of injured workers breaking into tears before them when desperately needed refill medication is denied.

Of course, some medications are more important than others.  Some result in devastating side effects if suddenly discontinued.  Other medications relieve pain and can leave an injured workers in agony for a couple of weeks while waiting for refill approval. Fortunately, there is a very simple solution to this problem.  Perhaps, instead of suddenly cutting off all medication, a claims administrators should automatically allow a partial refill of up to two weeks whenever an updated UR authorization is required.  This procedure will give everyone time to obtain the necessary approval while avoiding devastating consequences.  Keep in mind that we are not talking about a new medication, but only a refill of a previously approved drug that was previously agreed was necessary to treat the industrial injury. Again, the goal is to avoid cutting someone off from medication simply because a new UR approval is required.

Our readers may be asking if it is allowed by law to authorize only a partial refill.  Fortunately, back in 2017 the state of California passed AB-1048, effective July 1, 2018, adding section 4052.10 to the Business and Professions Code and section 136743 to the Health and Safety Code, authorizing partial refills of schedule II through V medications. Therefore, partial refills are allowed in California.

It is questionable if claim administrators and UR nurses are truly aware of the Rx refill problems described in today’s blog. We at F+B urge our readers to share this article with those handling claims, such that injured workers are not subjected to pain and suffering while waiting for refill authorization, especially when a partial refill is allowed by law. For further educational assistance feel free to contact the experts here at Friedman + Bartoumian.