We have noticed an alarming trend in workers' compensation, again rates are being raised and benefits to injured workers are being cut.

Begining July 2014 Travelers (verbal notice), Segwick and AIG Insurance, to name a few, have instituted a "Pharmacy Benefit Plan (PBN)" . These carriers now decline to reimburse physicians and clinics for medications dispensed to injured workers; they are now requiring that ALL prescriptions be filled at a local pharmacy. Numerous patients have returned to the clinic reporting that they have had submit payment in order to have their prescription filled.  Prior to these changes it was considered usual and customary in the workers' compensation arena for physicians and clinics to directly dispense medications to your injured employees then be reimbursed for these medications at the rate published by the California DWC Official Pharmacy Fee Schedule.  

Currently when an employee requires medication for a work related injury they will be referred to a pharmacy to fill the prescription. In order for the pharmacist to fill the prescription the patient will need to present a Pharmacy Benefit Card and Claim Number. A pharmacy benefit card alone does not guarantee the pharmacy they will receive payment for the prescription filled, they MUST have a established Workers' Comp claim and Claim number.

Our organization have developed and adopted 4 protocols in order to ensure that your injured employee recieves their prescription medications promptly. We ask that you review the available protocols and select the one that is right for you and your employees. 

PBN Protocol 1:

The employer agrees to contact their insurance carrier and establish a claim prior to referring the patient to the medical center for their initial evaluation. The employer agrees to provide a claim number on the treatment authorization form. Following completion of the initial examination / treatment the patient will be referred to a local pharmacy to fill a prescription(s), if necessary, for medicines or medical supplies   reasonably required/necessary to cure or relieve the injured employee from the effects of the injury. The pharmacy will fill and HOLD the prescription(s) until they receive written authorization from the insurance adjuster that the claim will be paid; this process requires 48 - 72 hours to complete. Only then, when written authorization is received, will the prescription be dispensed to your employee.

PBN Protocol 2:

Under California Labor Code Section 3753, the employer agrees to enter into a third party billing arrangement with our organization. The employer agrees to allow health care providers from our organization to directly dispense, if necessary, medicines or medical supplies reasonably required/necessary to cure or relieve the injured employee from the effects of the injury. The employer agrees to reimburse our organization for medicine(s) dispensed in compliance with the State of California Official Pharmacy Fee Schedule (-10%) within 60 days from the date the medicine was dispensed. 

PBN Protocol 3:

Under California Labor Code Section 3753, the employer agrees to enter into a third party billing arrangement with our organization. The employer agrees to allow health care providers from our organization to directly dispense, if necessary, medicines or medical supplies reasonably required/necessary to cure or relieve the injured employee from the effects of the injury. The initial bill for directly dispensed medicine(s) will be sent to the insurance carrier for payment. If the bill is returned unpaid, the employer agrees to reimburse our organization for medicine(s) dispensed in compliance with the State of California Official Pharmacy Fee Schedule within 90 days from the date the medicine was dispensed. 

PBN Protocol 4:

The employer agrees to obtain a blanket "letter of authorization" from their insurance carrier allowing licensed health care providers within our organization to directly dispense medicines or medical supplies reasonably required/necessary to cure or relieve the injured employee from the effects of the injury. The initial bill for directly dispensed medicine(s) will be sent to the insurance carrier for payment. If the bill is returned unpaid, the employer, under California Labor Code Section 3753, guarantees to reimburse our organization for medicine(s) dispensed in compliance with the State of California Official Pharmacy Fee Schedule (-10%) within 90 days from the date the medicine was dispensed.

PLEASE CONTACT A REPRESENTATIVE AT OUR CENTER IMEDIATELY TO DISCUSS WHICH PROTOCOL IS RIGHT FOR YOUR EMPLOYEES AND ORGANIZATION. 

IN GOOD FAITH OUR HEALTH CARE PROVIDERS WILL CONTINUE TO DISPENSE MEDICATIONS AS USUAL UNTIL 9/30/2014.

ALL ORGANIZATIONS THAT FAIL TO RESPOND TO THIS POSTING WILL AUTOMATICALLY BE ASSIGNED: PBN Protocol 1