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How Does Workers’ Comp Prescription Drug Coverage Work?

An employee's right to prescription drugs under workers' compensation:

Prescription drugs are a crucial part of your recovery process after a work-related injury, but workers' compensation insurance carriers will sometimes refuse to pay for the drugs, though you are entitled to them. A common problem that our clients encounter when attempting to seek medical treatment for work related injuries is that worker's comp insurance companies are reluctant to pay anything. Some items of compensation they will concede, but they will fight you vehemently on every other portion of your claim. One specific issue our clients repeatedly face is having worker's comp insurance deny them prescription drugs.

This may sound minor in comparison to other treatment the insurance company may choose to challenge, but prescription drugs are a very important part of your recovery process. Sometimes these prescription drugs are painkillers or antibiotics. Again, although this seems like a small part of the recovery process, it is vital to a successful recovery. We have helped clients with this issue in the past and were able to have worker's comp insurance cover their prescription drugs. Below, we will outline what Texas law says about prescription drugs and worker's comp coverage to help you assert your rights as a worker.

Questions Answered on This Page:

  • How do I get my prescriptions paid for under workers' comp?
  • Does worker's comp cover pain medication and prescriptions?
  • How do I make sure I get my pain medication paid for after being injured on the job?

The Texas Labor Code establishes your right to needed medications.

The law governing this issue is actually found in Section 408.028 of the Texas Labor Code and states the following:

  • (a) A physician providing care to an employee under this subchapter shall prescribe for the employee any necessary prescription drugs, and order over-the-counter alternatives to prescription medications as clinically appropriate and applicable, in accordance with applicable state law and as provided by Subsection (b). A doctor providing care may order over-the-counter alternatives to prescription medications, when clinically appropriate, in accordance with applicable state law and as provided by Subsection (b).
  • (b) The commissioner by rule shall require the use of generic pharmaceutical medications and clinically appropriate over-the-counter alternatives to prescription medications unless otherwise specified by the prescribing doctor, in accordance with applicable state law. The commissioner by rule shall adopt a closed formulary under Section 413.011. Rules adopted by the commissioner shall allow an appeals process for claims in which a treating doctor determines and documents that a drug not included in the formulary in necessary to treat an injured employee's compensable injury.
  • (c) Except as otherwise provided by this subtitle, an insurance carrier may not require an employee to use pharmaceutical services designated by the carrier.
  • (d) The commissioner shall adopt rules to allow an employee to purchase over-the-counter alternatives to prescription medications prescribed or ordered under Subsection (a) or (b) and to obtain reimbursement from the insurance carrier for those medications.
  • (e) Notwithstanding Subsection (b), the commissioner by rule shall allow an employee to purchase a brand name drug rather than a generic pharmaceutical medication or over-the-counter alternative to a prescription medication if a health care provider prescribes a generic pharmaceutical medication or an over-the-counter alternative to a prescription medication. The employee shall be responsible for paying the difference between the cost of the brand name drug and the cost of the generic pharmaceutical medication of of an over-the-counter alternative to a prescription medication. The employee may not seek reimbursement for the different in cost from an insurance carrier and is not entitles to use the medical dispute resolution provisions of Chapter 413 with regard to the prescription. A payment described by this subsection by an employee to a health care provider does not violate Section 413.042. This subsection does not affect the duty of a health care provider to comply with the requirements of Subsection (b) when prescribing medications or ordering over-the-counter alternatives to prescription medications.
  • (f) Notwithstanding any other provision of this title, the commissioner by rules shall adopt a fee schedule for pharmacy and pharmaceutical services that will:
    1. provide reimbursement rates that are fair and reasonable;
    2. assure adequate access to medications and services for injured workers;
    3. minimize costs to employees and insurance carriers; and
    4. take into consideration the increased security of payment afforded by this subtitle.
  • (g) Section 413.011(d) and the rules adopted to implement that subsection do not apply to the fee schedule adopted by the commission under Subsection (f).

Basically, this states that you have the right to prescription drug coverage under worker's compensation. It establishes that your treatment is strictly between you and your doctor, and if your doctor deems it appropriate to prescribe prescription medication, then you have the right for it to be paid by your worker's compensation coverage. Furthermore, this statute gives you the right to choose whether you purchase a brand name drug or a generic form of the medication, unless otherwise ruled by the commissioner.

Many insurance carriers will attempt to deny you this right, despite what the law says. Insurance carriers generally want to pay out as little money as possible, so they will attempt to deny you the right to prescription medication altogether, or they will claim that you are only afforded generic medication. They know that many workers who are injured are unaware or unfamiliar with the law regarding this issue, and unfortunately the worker's compensation insurance carriers will intentionally try to mislead you regarding your rights.

We deal with the insurance companies so you don't have to.

Hopefully, this illustrates why you need a reputable law firm to represent you and deal with these worker's compensation insurance carriers on your behalf. Insurance companies may be able to get away with being underhanded and deceitful with some people, but not with our experienced attorneys. Our experience and our aggressive stance on worker's compensation cases gives us an edge over the insurance carriers, and we have beaten them countless times in the past.

Don't be pushed around by a misleading or deceitful worker's compensation insurance carrier, hire our experienced attorneys to fight your case. In order for your rights to be adequately protected and represented, you need an on-the-job injury attorney. Call Grossman Law Offices at (855) 326-0000.

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